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 his chest.
The nurse should identify that the client has developed which of the following types of transfusion reactions?
Allergic.
Febrile nonhemolytic.
Acute hemolytic.
Bacterial.
The Correct Answer is C
Choice A rationale:
Allergic transfusion reactions are characterized by symptoms such as hives, itching, and shortness of breath. While allergic reactions can cause discomfort, they do not typically present with the symptoms described in the scenario, such as chills, headache, low-back pain, and chest tightness.
Choice B rationale:
Febrile nonhemolytic transfusion reactions are characterized by fever and chills, but they do not usually cause headache, low-back pain, or chest tightness. These reactions occur due to antibodies against donor leukocytes or platelets.
Choice C rationale:
Acute hemolytic transfusion reactions occur when there is a mismatch in blood type between the donor and recipient, leading to rapid destruction of transfused red blood cells. This reaction can cause symptoms such as chills, fever, low-back pain, chest tightness, and hemoglobinuria (presence of hemoglobin in the urine) It is a medical emergency that requires immediate cessation of the transfusion, supportive care, and treatment for potential complications such as acute kidney injury.
Choice D rationale:
Bacterial transfusion reactions occur due to bacterial contamination of the blood product. These reactions can cause symptoms such as fever, chills, hypotension, and shock. While bacterial transfusion reactions can be serious, the symptoms described in the scenario, including headache and low-back pain, are not typically associated with this type of reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To calculate how many tablets of levothyroxine the nurse should administer, we'll need to convert the dose to the same unit as the available tablets. Here's the step-by-step process:
Convert the desired dose to milligrams (mg): 50 micrograms (mcg) = 50 / 1000 mg (since 1 mg = 1000 mcg) 50 mcg = 0.05 mg
Now, find out how many tablets of 0.025 mg each are required to achieve the desired dose: Number of tablets = Desired dose (in mg) / Tablet strength (in mg) Number of tablets = 0.05 mg / 0.025 mg Number of tablets = 2 tablets
Therefore, the nurse should administer 2 tablets per dose.
Correct Answer is D
Explanation
Incorrect. Rounding the edges of toenails can lead to ingrown toenails, which should be avoided.
B. Incorrect. Soaking feet twice daily can lead to dry skin and potentially increase the risk of infection, so it's not recommended.
C. Incorrect. Using moisturizing lotion between the toes can also increase the risk of moisture-related skin issues. It's better to keep the area between the toes dry.
D. Correct. Wearing clean cotton socks helps maintain proper foot hygiene and prevents moisture accumulation, reducing the risk of fungal infections.
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