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 C

Explanation

A. Elevate the limb and apply ice. Elevating the limb and applying ice can help reduce blood flow to the area and minimize swelling. However, it is not the immediate priority in managing active, profuse bleeding.

B. Apply a tourniquet just below the elbow. A tourniquet should be a last resort due to the risk of cutting off blood flow and potential limb damage. It's typically used in life-threatening situations where other methods fail to control bleeding.

C. Apply direct pressure over the wound. The immediate priority for controlling profuse bleeding is to apply direct pressure to the wound to stop or reduce the bleeding. This is a standard first-line intervention in hemorrhage management.

D. Clean the wound. Cleaning the wound is important to prevent infection, but it is not the first priority when dealing with active, profuse bleeding.

A. Keep family members aware of his condition. B. Talk with the client during wound care. C. Rotate nursing staff so he can have varied interactions. D. Assign assistive personnel to keep his room neat and clean.

Correct Answer is B

Explanation

A. Keep family members aware of his condition: While important, keeping family informed is not as directly impactful on the client’s emotional support as direct interaction with the client.

B. Talk with the client during wound care. Talking with the client during wound care can help to establish a trusting relationship, provide emotional support, and help the client cope with the pain and stress associated with burn treatment.

C. Rotate nursing staff so he can have varied interactions: Continuity of care is often more comforting to clients than having varied interactions.

D. Assign assistive personnel to keep his room neat and clean: This task is important for infection control but does not directly provide emotional support.

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?

Correct Answer is C

Explanation

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Correct Answer is B

Explanation

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