A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
Anaphylactic
Acute hemolytic
Febrile
Circulatory overload
The Correct Answer is A
A. An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.
B. An acute hemolytic reaction is incorrect. This reaction occurs when the recipient's immune system attacks incompatible donor red blood cells, leading to symptoms such as fever, chills, flank pain, hypotension, and hemoglobinuria. Urticaria and wheezing are not characteristic symptoms of this reaction.
C. A febrile reaction is incorrect. Febrile reactions are the most common type of transfusion reaction and are typically characterized by fever, chills, and headache, rather than urticaria or wheezing.
D. Circulatory overload is incorrect. This reaction occurs when too much fluid is infused too quickly, leading to dyspnea, hypertension, and pulmonary edema. While respiratory distress can occur, it is not accompanied by urticaria, which is specific to an allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Verify the medication three times with the medication administration record.": This is the best practice for ensuring the correct medication is administered. The nurse should verify the medication when removing it from storage, before preparing the medication, and at the bedside before giving it to the patient to ensure the right drug, dose, patient, time, and route.
B. "Administer time-critical medication 60 min before or after the scheduled time.": Time-critical medications should be administered within a specified window of 30 minutes before or after the scheduled time, not 60 minutes. Administering medication too early or late could compromise its effectiveness.
C. "Identify the client by using one identifier before giving the medication.": The correct approach is to use two identifiers (e.g., name and date of birth) to verify the client's identity, not just one. This reduces the risk of medication errors.
D. "Document medication administration prior to administering medication.": Documentation should occur after medication administration, not before, to ensure accurate recordkeeping of the event.
Correct Answer is D
Explanation
A. Tell the client she should discuss this decision with her family.: This is incorrect. While family involvement can be important in decisions regarding treatment, the nurse should respect the client's autonomy and support their right to make decisions about their own care.
B. Discuss alternative treatment methods with the client.: This is incorrect. Since the client has already made the decision to stop dialysis, the nurse should not push alternative treatment methods. The focus should be on supporting the client’s decision rather than presenting options they have chosen not to pursue.
C. Ask the facility chaplain to visit the client.: While a chaplain may provide valuable spiritual support, this is not the first action the nurse should take. It is more important to first support the client’s decision and ensure they are informed about the consequences.
D. Support the client's decision to stop the treatment.: This is correct. The nurse should support the client’s decision and provide care that aligns with the client’s values and wishes. It’s important to respect the client's right to make informed choices about their care, including the decision to discontinue dialysis.
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