A nurse is monitoring a client who has just started a blood transfusion. After 30 minutes, the client reports shaking chills, muscle stiffness, and a temperature of 39 C (102.2 F) The client denies having any low back pain, nausea, chest tightness, dyspnea, and anxiety. Which type of transfusion reaction should the nurse suspect?
Acute hemolytic reaction
Septic reaction
Non-hemolytic febrile reaction
Allergic reaction
The Correct Answer is C
Rationale:
A. Acute hemolytic reactions are typically caused by incompatible blood transfusions. They present with fever, chills, hypotension, low back pain, hemoglobinuria, dyspnea, and anxiety. The absence of low back pain, hypotension, or hemoglobinuria makes an acute hemolytic reaction less likely in this scenario.
B. Septic transfusion reactions result from bacterial contamination of the blood product. Symptoms include high fever, chills, hypotension, tachycardia, and shock, often progressing rapidly. The client’s stable hemodynamics and absence of systemic signs of sepsis make this less likely.
C. This is the most common type of transfusion reaction and is typically caused by antibodies to donor leukocytes. It presents with shaking chills, fever, and muscle stiffness, usually without hypotension, dyspnea, or hemoglobinuria. The reaction often occurs within the first 30–90 minutes of transfusion, matching this client’s presentation.
D. Allergic reactions usually involve urticaria, pruritus, flushing, and sometimes angioedema. Fever and muscle stiffness are not typical, so this client’s symptoms are inconsistent with an allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale:
The client’s symptoms of morning stiffness, symmetrical joint involvement (hands and knees), swelling of proximal interphalangeal joints, and elevated ESR and CRP with a positive rheumatoid factor are characteristic of rheumatoid arthritis. This autoimmune condition causes chronic inflammation of synovial joints, leading to pain, stiffness, and decreased function.
Encouraging range of motion exercises helps maintain joint flexibility, prevent contractures, and improve mobility in clients with rheumatoid arthritis. Administering anti-inflammatory medications reduces joint inflammation, alleviates pain, and slows disease progression.
Monitoring pain level provides insight into the effectiveness of treatment and the client’s functional status. Assessing joint swelling helps evaluate the degree of inflammation and progression or improvement of the disease.
Correct Answer is B
Explanation
Rationale:
A. Opioids like fentanyl are not typically associated with increased urination or incontinence. In fact, they may cause urinary retention rather than increased output. Therefore, this is incorrect.
B. Fentanyl is a potent opioid analgesic that can significantly depress the central nervous system, particularly the respiratory center in the brain. High doses increase the risk of respiratory depression, which can lead to hypoventilation, hypoxia, and potentially death if not promptly recognized and managed. This is the most critical adverse effect to monitor, making this the correct answer.
C. Opioids generally do not cause increased heart rate; they are more likely to cause bradycardia due to their depressant effects on the central nervous system. Therefore, this is incorrect.
D. Fentanyl is more commonly associated with hypotension rather than elevated blood pressure due to vasodilation and decreased sympathetic tone. Therefore, this option is incorrect.
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