A nurse is assisting with the care of a client who is receiving 1 unit of packed RBCs. The client is coughing and reports a headache and difficulty breathing. The client's vital signs indicate tachycardia and hypertension. The nurse should identify that the client is experiencing which of the following types of transfusion reactions?
Circulatory overload
Mild allergic
Febrile nonhemolytic
Sepsis
The Correct Answer is A
A. Circulatory overload
Signs like cough, dyspnea, tachycardia, and hypertension are classic features of fluid overload due to rapid transfusion or volume excess.
B. Mild allergic
Presents with itching, hives, or flushing—not respiratory distress or hypertension.
C. Febrile nonhemolytic
Presents with fever, chills, and malaise, but not cough, headache, or hypertension.
D. Sepsis
Involves hypotension, fever, chills, and shock-like symptoms—not hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client who is 4 days postpartum and has lochia serosa
This is an expected finding in the healing process.
B. A client who is 3 days postpartum and has not had a bowel movement
Common postpartum; not urgent unless severe discomfort or obstruction is present.
C. A client who is 1 day postpartum and has not voided in 8 hr
Urinary retention increases the risk of uterine atony and postpartum hemorrhage-must be addressed urgently.
D. A client whose fundus is 2–4 cm below the umbilicus on day 2
Normal involution of the uterus; not concerning.
Correct Answer is C
Explanation
A. Hypoglycemia
Lithium does not typically affect blood glucose levels.
B. Constipation
Diarrhea, not constipation, is a more common symptom of lithium toxicity.
C. Muscle irritability
Muscle weakness, tremors, and neuromuscular irritability are signs of lithium toxicity (level >1.5 mEq/L).
D. Increased BP
Lithium toxicity does not cause hypertension; it may actually cause hypotension in severe cases.
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