A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?
The blood was infused too quickly and overwhelmed the client's circulatory system.
The donor blood was incompatible with that of the client.
The client had a sensitivity reaction to a plasma protein in the blood.
Antibodies to donor leukocytes remained in the blood.
The Correct Answer is B
A. The blood was infused too quickly and overwhelmed the client's circulatory system:
While infusing blood too quickly can lead to circulatory overload and related complications like heart failure or pulmonary edema, it is not the cause of an acute hemolytic transfusion reaction. Acute hemolytic reactions occur due to immune responses against incompatible donor blood.
B. The donor blood was incompatible with that of the client:
This is the correct answer. An acute hemolytic transfusion reaction happens when there is an incompatibility between the donor's blood and the recipient's blood. This can occur due to mismatched ABO blood types or Rh factor, leading to the recipient's immune system attacking and destroying the transfused red blood cells.
C. The client had a sensitivity reaction to a plasma protein in the blood:
Sensitivity reactions to plasma proteins can occur, but they typically result in different types of transfusion reactions, such as allergic reactions or febrile non-hemolytic reactions. These reactions are caused by antibodies to specific plasma proteins and are not the cause of acute hemolytic transfusion reactions.
D. Antibodies to donor leukocytes remained in the blood:
This option refers to febrile non-hemolytic transfusion reactions, which occur due to antibodies against donor leukocytes. However, this type of reaction is distinct from acute hemolytic reactions, which are primarily caused by ABO or Rh incompatibility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The test is noninvasive, and nothing will be inserted into the client's body: Transthoracic echocardiography (TTE) is a noninvasive procedure that uses ultrasound waves to create images of the heart. It involves placing a transducer on the chest wall to capture images of the heart's structure and function. The nurse should inform the client that no instruments or devices will be inserted into their body during the test.
B. The client will remain on bed rest for 1 to 2 hours after the test: This statement is not typically accurate for a TTE procedure. After a TTE, clients can usually resume their normal activities without any specific bed rest requirements, unless otherwise specified by the healthcare provider based on individual circumstances.
C. The client's pain will be managed aggressively during the procedure: TTE is generally a painless procedure that does not require aggressive pain management. The client may feel slight discomfort from the transducer's pressure on the chest, but it is typically well tolerated without the need for pain medication.
D. The test will provide a detailed profile of the heart's electrical activity: While echocardiography provides detailed images of the heart's structure and function, including information about blood flow and valve function, it does not directly assess the heart's electrical activity. For evaluating electrical activity, other tests such as electrocardiography (ECG or EKG) would be used.
Correct Answer is C
Explanation
A. 120/80 mm Hg or lower:
This blood pressure range is considered normal or optimal for most adults. However, for individuals diagnosed with hypertension, the goal is typically to reduce blood pressure to below 140/90 mm Hg, as maintaining normal blood pressure is not considered a goal for hypertension treatment unless specifically indicated based on individual circumstances.
B. Average of two BP readings of 150/80 mm Hg:
A blood pressure reading of 150/80 mm Hg is elevated and indicates hypertension, especially if consistently elevated across multiple readings. The goal of hypertension treatment is to lower blood pressure to below 140/90 mm Hg, so an average of 150/80 mm Hg would not be considered the goal of treatment.
C. 140/90 mm Hg or lower:
This blood pressure range is commonly recommended as the goal of treatment for individuals with hypertension who otherwise enjoy good health. It represents a balance between effective blood pressure control and minimizing the risk of side effects or complications associated with overly aggressive treatment.
D. 156/96 mm Hg or lower:
While a blood pressure reading of 156/96 mm Hg is elevated and indicates hypertension, the goal of treatment is typically to reduce blood pressure to below 140/90 mm Hg rather than targeting a specific numeric value below 156/96 mm Hg.
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