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

Answer and Explanation

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 A

Explanation

A. Scatter rugs are present in the kitchen - Scatter rugs can cause tripping and slipping, posing a significant fall risk for someone with vision impairment.

B. Handrails are present in the bathroom - Handrails provide support and help prevent falls, making them a safety feature, not a risk.

C. Electrical cords are placed along the walls - This helps prevent tripping over cords, thus reducing fall risk.

D. Uses a microwave for cooking - A microwave is generally safer than a stove as it reduces the risk of burns and fires, making it a safety feature.

A. Allergic B. Acute pain C. Febrile D. Hemolytic

Correct Answer is D

Explanation

A. Allergic: Allergic reactions typically involve symptoms such as hives, itching, and sometimes anaphylaxis, but not usually fever, chills, or hematuria (red-tinged urine).

B. Acute pain: Acute pain transfusion reaction is characterized by severe pain but not usually accompanied by fever, chills, or hematuria.

C. Febrile: Febrile reactions involve fever and chills but do not typically include red-tinged urine, which indicates hemolysis of red blood cells.

D. Hemolytic: A hemolytic transfusion reaction involves the destruction of red blood cells, leading to fever, chills, and red-tinged urine due to the presence of hemoglobin from lysed red cells in the urine.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Correct Answer is D

Explanation

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?

A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.]

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?