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A nurse is monitoring a client who is receiving 2 units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

Bradycardia

Hypertension

Back pain

Chills

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Bradycardia - Bradycardia is not a typical symptom of a haemolytic transfusion reaction.

Choice B Reason;

Hypertension - Hypertension is not a common manifestation of a haemolytic transfusion reaction.

Choice C Reason:

Back pain A haemolytic transfusion reaction is a severe and potentially life-threatening complication that can occur when the immune system reacts against the transfused red blood cells. Back pain is a classic symptom of a haemolytic transfusion reaction. It is often accompanied by other symptoms such as fever, chills, chest pain, dyspnoea, nausea, vomiting, haematuria, and hemoglobinuria (presence of haemoglobin in the urine).

Choice D Reason:

Chills - Chills can occur in various types of transfusion reactions, including haemolytic reactions, but they are not as specific as back pain for indicating a haemolytic transfusion reaction.

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Correct Answer is C

Explanation

Choice A Reason:

Diplopia is incorrect. Diplopia is double vision and is not a specific sign of malnutrition.

Choice B Reason:

Hyperproteinemia is incorrect - Malnutrition often leads to hypoalbuminemia (low levels of albumin, a protein), not hyperproteinemia.

Choice C Reason:

Cachexia is correct. Cachexia refers to a state of severe malnutrition and muscle wasting that can occur in individuals with chronic illnesses, especially advanced cancer, heart failure, or certain inflammatory conditions. It is characterized by significant weight loss, muscle atrophy, weakness, and fatigue. Cachexia goes beyond simple malnutrition and is a more severe manifestation of nutritional deficiency.

Choice D Reason:

Hypermagnesemia is incorrect - Malnutrition is more likely to cause deficiencies in minerals like magnesium, not excess levels (hypermagnesemia).

A. The client reports being extremely thirsty with a sore throat. B. The client's abdomen becomes distended and firm. C. The drainage is bright green in color with brown fecal material D. The amount of drainage is gradually decreasing

Correct Answer is C

Explanation

Choice A Reason:

The client reports being extremely thirsty with a sore throat - This could be due to the presence of the NG tube and suctioning, but it is not as immediately concerning as the change in drainage colour.

Choice B Reason:

The client's abdomen becomes distended and firm - While this could indicate a possible complication, it is not as directly related to the change in drainage colour.

Choice C Reason:

The drainage is bright green in colour with brown faecal material the finding that the drainage from the NG tube is bright green in colour with brown faecal material should be reported to the provider. This change in the colour and appearance of the drainage can be indicative of bilious (greenish-yellow) vomiting, which may suggest an obstruction or another underlying issue. It's important to assess the client's condition and inform the provider about any significant changes in their symptoms.

Choice D Reason:

The amount of drainage is gradually decreasing - Gradually decreasing drainage could be expected as the condition improves, but it's not as alarming as a change in the drainage colour.

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A nurse is monitoring a client who is receiving 2 units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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