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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
75 mL of greenish-yellow drainage should not be reported. This could be stomach contents or bile, which can be expected after surgery and might not be alarming.
Choice B reason:
150 mL of serosanguineous drainage should not be reported. Serosanguineous drainage is a mix of clear and slightly bloody fluid, which can be expected after surgery and may not be alarming.
Choice C reason:
100 mL of red drainage should be reported. After abdominal surgery, the drainage from an NG (nasogastric) tube is monitored to assess the client's condition and the status of their gastrointestinal system. Red drainage could indicate bleeding, which is a significant concern after surgery. The nurse should report this finding to the provider for further evaluation and intervention.
Choice D reason:
200 mL of brown drainage should not be reported. Brown drainage could also be indicative of old blood or digestive fluids, which might be expected after surgery and may not be alarming.
Correct Answer is D
Explanation
Choice A Reason:
Applying lotion between the toes - Applying lotion between the toes can create a moist environment that may increase the risk of fungal infections. Lotion application should be done on the tops and bottoms of the feet, avoiding the spaces between the toes.
Choice B Reason:
Inspecting the feet every other day - Daily foot inspections are recommended for individuals with diabetes to identify any changes or abnormalities early and prevent potential complications.
Choice C Reason:
Soaking the feet twice a day - Excessive soaking of the feet can lead to maceration of the skin and increase the risk of infection, so it's generally not recommended. Regular washing with mild soap and water is sufficient for foot hygiene.
Choice D Reason
Trim toenails straight across When providing discharge teaching about foot care to a client with diabetes, the nurse should include information about proper foot care practices to prevent complications. Trimming toenails straight across is recommended to avoid ingrown toenails and potential injury. This reduces the risk of foot complications that can arise due to diabetes-related circulatory and neuropathic changes.
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