A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?
Temperature 38.8° C (101.8° F)
Straw-colored urine
Apical pulse rate 58/min
Blood pressure 158/92 mm Hg
The Correct Answer is A
The correct answer is: a. Temperature 38.8° C (101.8° F)
Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.
Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.
Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.
Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
As a nurse, the intervention that should be recommended is encouraging the client to take frequent walks during the day. This will help the client expend some energy and reduce the restlessness that could be causing the sleep disturbance at night.
The other options are not recommended because barbiturate medications can cause excessive sedation, allowing the client to nap for at least 1 hour during the day can interfere with their ability to sleep at night, and putting a lock on the client's door can be a safety risk in case of an emergency.
Correct Answer is D
Explanation
This statement shows that the client understands the threshold for high blood pressure readings. A blood pressure reading of 140/90 mmHg or higher is considered elevated or hypertensive.
It is important for the client to be aware of this value and to seek medical attention or follow the prescribed management plan if their blood pressure exceeds this threshold.
The hand should be supported at the level of the heart or positioned comfortably during blood pressure measurement, but it does not need to be specifically 6 inches below the heart.
Consistency in the timing of blood pressure measurements is important for accurate monitoring. It is generally recommended to measure blood pressure at the same time each day to account for variations that can occur throughout the day.
The blood pressure cuff should be snug but not too tight around the upper arm. It should fit comfortably and securely to ensure accurate readings.
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