A nurse is monitoring a client who is receiving 2 units of packed RBCs.
Which of the following manifestations indicates a hemolytic transfusion reaction?
Back pain.
Bradycardia.
Hypertension.
Chills.
The Correct Answer is A
The correct answer is A. Back pain.
Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
One of the lifestyle changes that doctors recommend for managing symptoms of gastroesophageal reflux disease (GERD) is elevating the head during sleep by placing a foam wedge or extra pillows under the head and upper back to incline the body and raising the head off the bed 6 to 8 inches.
Choice A: “Increase your caloric intake by 250 calories per day” is not an answer because it is not mentioned as a self-management strategy for GERD in my sources.
Choice B: “Lie down for 30 minutes after each meal” is not an answer because it is not mentioned as a self-management strategy for GERD in my sources.
Choice C: “Eat a light meal 1 hour before bedtime” is not an answer because it is not mentioned
Correct Answer is B
Explanation
After inhaling deeply using an incentive spirometer, you should hold your breath for 3 to 5 seconds before exhaling.
Choice A is wrong because exhaling slowly through pursed lips is not an instruction for using an incentive spirometer.
Choice C is wrong because placing hands on the upper abdomen during inhalation is not an instruction for using an incentive spirometer.
Choice D is wrong because positioning the mouthpiece.5 cm (1 in) from the mouth is not an instruction for using an incentive spirometer.
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