A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?
Acute hemolytic
Allergic
Febrile nonhemolytic
Bacterial
The Correct Answer is A
Choice A reason: Acute hemolytic reaction is the most severe and potentially life-threatening transfusion reaction. It occurs due to ABO incompatibility and presents with symptoms such as chills, fever, low-back pain, chest tightness, and hemoglobinuria. Immediate cessation of the transfusion and emergency intervention are required.
Choice B reason: Allergic reactions typically present with urticaria, itching, and mild respiratory symptoms. They do not usually involve chest tightness or back pain.
Choice C reason: Febrile nonhemolytic reactions are common and usually present with fever and chills but lack the severe systemic symptoms like chest tightness and back pain.
Choice D reason: Bacterial contamination of blood products can cause fever and hypotension, but it is less likely to present with the specific constellation of symptoms described here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Documenting the presence of a living will is essential during admission. It ensures that the client’s advance directives are known and respected throughout care.
Choice B reason: Admission data should be documented immediately and thoroughly, not summarized later during shift change. Delayed documentation risks omissions and errors.
Choice C reason: Nurses must validate and document their own assessments. Vital signs taken by assistive personnel should be verified before being charted.
Choice D reason: Charting should begin with objective data collection, not evaluation. Evaluation is part of the nursing process but follows assessment and planning.
Correct Answer is A
Explanation
Choice A reason: Applying petroleum jelly with each diaper change protects the healing site from friction and prevents the diaper from sticking to the wound. This promotes comfort and proper healing.
Choice B reason: Alcohol is too harsh for the healing circumcision site and can cause irritation and delayed healing. Gentle cleansing with warm water is preferred.
Choice C reason: Using the diaper to apply pressure is not recommended. Gentle handling is essential to avoid trauma to the healing tissue.
Choice D reason: Yellow drainage is part of the normal healing process and should not be wiped off. Removing it can disrupt healing and increase the risk of infection.
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