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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: This is not a problem for a client who has hypertension and a new prescription for metoprolol, as metoprolol is a beta-blocker that can reduce the workload of the heart and improve the symptoms of heart failure.

Choice B reason: This is not a problem for a client who has hypertension and a new prescription for metoprolol, as metoprolol does not have any significant interactions with antibiotics or other medications used to treat pneumonia.

Choice C reason: This is a problem for a client who has hypertension and a new prescription for metoprolol, as tadalafil is a phosphodiesterase-5 inhibitor that can lower the blood pressure and cause hypotension when taken with metoprolol. The nurse should investigate further and notify the provider of the potential interaction.

Choice D reason: This is not a problem for a client who has hypertension and a new prescription for metoprolol, as metoprolol does not affect the blood glucose levels or the management of diabetes.

A. Administer low dose aspirin. B. Prepare for autologous blood transfusion. C. Obtain a stool specimen. D. Apply heat to the knee.

Correct Answer is C

Explanation

The correct answer is: D. Apply heat to the knee.

Choice A reason:

Administering low dose aspirin is not appropriate for clients with hemophilia A because aspirin can inhibit platelet function and increase the risk of bleeding. Hemophilia A patients already have a deficiency in clotting factor VIII, and adding aspirin can exacerbate bleeding tendencies.

Choice B reason:

Preparing for an autologous blood transfusion is not a standard treatment for hemarthrosis in hemophilia A. The primary treatment involves factor replacement therapy to address the underlying clotting deficiency. Blood transfusions are generally reserved for severe cases of anemia or significant blood loss.

Choice C reason:

This action is appropriate to assess for gastrointestinal bleeding, which can be a concern in clients with hemophilia due to the risk of spontaneous bleeding. Monitoring for signs of internal bleeding is crucial.

Choice D reason:

Heat application is generally avoided in acute bleeding episodes, as it can increase blood flow and potentially worsen bleeding. Ice is preferred to reduce swelling and pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further?

Correct Answer is C

Explanation

A nurse is caring for a client who has hemophilia A and hemarthrosis of the left knee. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is providing teaching for a client who has hypertension and a prescription change from metoprolol to metoprolol/hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?

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