A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic. reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
Hemolytic
Allergic
Febrile
Bacterial
The Correct Answer is A
A. Hemolytic: Acute hemolytic transfusion reactions can occur quickly after starting a transfusion and present with symptoms such as fever, chills, headache, low back pain, tachycardia, and apprehension. It is a serious reaction caused by the destruction of transfused red blood cells.
B. Allergic: Allergic reactions to blood transfusions typically present with hives, itching, and anaphylaxis, not low back pain or tachycardia.
C. Febrile: Febrile reactions involve fever and chills but not typically headache or back pain.
D. Bacterial: Bacterial contamination of blood can cause fever and chills, but not specifically the symptoms of headache and low back pain described.
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Correct Answer is C
Explanation
A. Hemoglobin level:While knowing the hemoglobin level helps determine the need for the transfusion, it is generally assessed and ordered by the provider before the transfusion is prescribed. It is important information but not the most immediate data required directly before administering the PRBCs.
B. Fluid intake:Monitoring fluid balance is important, especially in clients at risk for fluid overload, but it is not as immediately critical as temperature in detecting potential reactions to the transfusion.
C. Temperature:A baseline temperature is crucial to monitor for febrile reactions during the transfusion. Any significant rise in temperature can signal a transfusion reaction, which requires immediate intervention.
D. Skin color:Skin color can provide information on overall oxygenation and perfusion but is not as specific or immediately useful as temperature for monitoring for transfusion reactions.
Correct Answer is D
Explanation
A. Phlebotomist - Phlebotomists are trained in drawing blood and handling specimens but are not typically trained to verify blood products for transfusion.
B. Assistive personnel - Assistive personnel (e.g., nursing assistants) do not have the required training or authority to verify blood products for transfusion.
C. Senior nursing student - Although a senior nursing student may have some clinical experience, they do not have the qualifications or the responsibility required for this critical safety task.
D. Oncology nurse - An oncology nurse is a registered nurse with specialized training and experience in administering blood products and managing the associated risks, making them qualified to double-check blood labels and patient identification.
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