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. Placing the client in an orthopneic position is correct. The orthopneic position (sitting upright and leaning forward. helps clients with COPD breathe more easily by maximizing lung expansion and easing the work of breathing. This position is often used in clients with chronic respiratory conditions to alleviate dyspnea.
B. Providing the client with three large meals is incorrect. Clients with COPD may have difficulty eating large meals because it can interfere with breathing due to increased diaphragm pressure. Instead, small, frequent meals are recommended to reduce the workload on the respiratory system.
C. Encouraging the client to cough and deep breathe once every 8 hr is incorrect. In clients with COPD, frequent coughing and deep breathing exercises are important to promote airway clearance and lung expansion. The nurse should encourage these activities more often than every 8 hours, especially to help clear mucus.
D. Limiting fluid intake to 1,000 ml daily is incorrect. Adequate hydration is essential in COPD clients to help thin secretions and promote easier expectoration. A restriction on fluids could lead to thickened mucus and worsened respiratory status.
Correct Answer is B
Explanation
A. Denial is incorrect. Denial involves refusing to acknowledge reality or a distressing situation, which is not evident in this scenario. The adolescent is aware of the conflict and has chosen a constructive way to address it.
B. Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.
C. Regression is incorrect. Regression occurs when an individual reverts to an earlier stage of development in response to stress. Examples include an older child suddenly sucking their thumb or having temper tantrums. The adolescent in this scenario is demonstrating maturity, not regression.
D. Repression is incorrect. Repression involves unconsciously blocking distressing thoughts or emotions from awareness. The adolescent is not avoiding or forgetting about the conflict but is instead managing it through physical activity.
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