A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction?
Distended neck veins
Client report of low back pain
A productive cough
Client report of tinnitus
The Correct Answer is B
Choice A reason: Distended neck veins is not a manifestation of acute hemolytic reaction, but it may indicate fluid overload, which is another possible complication of blood transfusion. Fluid overload may occur when the blood volume or rate of infusion exceeds the client's circulatory capacity. Fluid overload may manifest as dyspnea, crackles, edema, hypertension, or tachycardia.
Choice B reason: Client report of low back pain is a manifestation of acute hemolytic reaction, which is a life-threatening condition that occurs when the donor blood is incompatible with the recipient's blood. Acute hemolytic reaction may occur within minutes or hours of the transfusion and may cause the destruction of the transfused red blood cells. Acute hemolytic reaction may manifest as fever, chills, low back pain, hemoglobinuria, hypotension, or shock.
Choice C reason: A productive cough is not a manifestation of acute hemolytic reaction, but it may indicate a respiratory infection, which is a potential risk of blood transfusion. Blood transfusion may transmit infectious agents, such as bacteria, viruses, or parasites, from the donor to the recipient. A productive cough may also be a sign of pulmonary edema, which may result from fluid overload or transfusion-related acute lung injury (TRALI).
Choice D reason: Client report of tinnitus is not a manifestation of acute hemolytic reaction, but it may indicate ototoxicity, which is a possible adverse effect of some medications, such as aminoglycosides, loop diuretics, or salicylates. Ototoxicity may damage the inner ear or the auditory nerve and cause hearing loss, tinnitus, or vertigo. The nurse should assess the client's medication history and monitor the client's hearing function.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is: d. The client uses garlic to lower cholesterol levels.
Choice A: The client follows a low-fat diet to reduce cholesterol
Following a low-fat diet to reduce cholesterol does not have a significant impact on the effects of warfarin. While diet can influence overall health and cholesterol levels, it does not directly interact with warfarin’s anticoagulant properties.
Choice B: The client drinks a glass of grapefruit juice every day
Grapefruit juice is known to interact with various medications by inhibiting the cytochrome P450 enzymes, particularly CYP3A4. However, grapefruit juice does not significantly affect warfarin metabolism. It is more commonly associated with interactions with statins and other medications.
Choice C: The client sprinkles flax seeds on food 1 hr before taking the anticoagulant
Flax seeds are rich in omega-3 fatty acids and fiber, which can be beneficial for heart health. However, there is no strong evidence to suggest that flax seeds significantly potentiate the effects of warfarin. They do not have a direct interaction with the anticoagulant properties of warfarin.
Choice D: The client uses garlic to lower cholesterol levels
Garlic is known to have antiplatelet properties, which can enhance the anticoagulant effects of warfarin. This can increase the risk of bleeding in clients taking warfarin. Garlic can interfere with the blood clotting process, making it a significant factor to consider when managing a client on warfarin.
Correct Answer is C
Explanation
Choice A reason: Vomiting is not a specific sign of a hemolytic reaction, as it can be caused by many other factors, such as anesthesia, infection, or medication. Vomiting may occur in other types of transfusion reactions, such as allergic or febrile reactions, but it is not indicative of hemolysis.
Choice B reason: Flushing is not a specific sign of a hemolytic reaction, as it can be caused by many other factors, such as fever, infection, or medication. Flushing may occur in other types of transfusion reactions, such as allergic or febrile reactions, but it is not indicative of hemolysis.
Choice C reason: Dyspnea is a specific sign of a hemolytic reaction, as it indicates that the client is experiencing respiratory distress due to the release of hemoglobin and its breakdown products into the bloodstream. Dyspnea may be accompanied by chest pain, cough, wheezes, or crackles. Dyspnea is a life-threatening symptom that requires immediate intervention.
Choice D reason: Hypotension is not a specific sign of a hemolytic reaction, as it can be caused by many other factors, such as blood loss, dehydration, or medication. Hypotension may occur in other types of transfusion reactions, such as septic or anaphylactic reactions, but it is not indicative of hemolysis.
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