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 C
Explanation
Choice A reason: Telling the client directly that the AP took the watch is inappropriate and could escalate the situation without proper investigation. The nurse must follow institutional protocols for reporting suspected theft.
Choice B reason: Confronting the AP may lead to conflict and compromise the integrity of the investigation. The nurse should report the incident through the proper chain of command.
Choice C reason: Reporting the observation to the immediate supervisor ensures that the incident is handled professionally and according to facility policy. It initiates a formal investigation and protects both the client and staff.
Choice D reason: Calling security may be necessary later, but the first step is to notify the supervisor. Security involvement should follow administrative review and protocol.
Correct Answer is C
Explanation
The correct answer is C. "Place a breath mint in the pouch."
When managing a new colostomy, controlling odor and flatus (gas) is a primary concern for client comfort and confidence. Here is a breakdown of why this is the correct instruction and why the other options are contraindicated.
Rationale for Instructions
| Instruction | Rationale |
| Place a breath mint in the pouch | Deodorizers (like breath mints or commercial pouch deodorants) help neutralize odors inside the appliance without interfering with the stoma. |
| Avoid chewing gum | Chewing gum increases the amount of swallowed air, which leads to increased flatus (gas) and pouch "ballooning." |
| Limit odor-causing foods | Eggs, fish, garlic, onions, and asparagus are known to cause significant odor and should be limited rather than encouraged. |
| Drink cranberry juice | Cranberry juice and yogurt are actually recommended because they can help decrease the odor of the stool. |
Additional Management Tips
To further assist with odor and flatus control, the following strategies are often recommended:
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Dietary Consistency: Eat at regular intervals to prevent the bowel from becoming hyperactive or excessively gassy.
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Avoid Straws: Drinking through a straw increases swallowed air, leading to more gas.
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Yogurt and Buttermilk: These can help regulate the bacterial flora in the gut, often reducing the pungency of gas.
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Charcoal Filters: Many modern ostomy pouches come with built-in charcoal filters that allow gas to escape while neutralizing the scent.
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