A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

The first 2 min

The final 2 min

The final 15 min

The first 15 min

Answer and Explanation

The Correct Answer is D

A. The first 2 min - This is too short a period to monitor effectively for transfusion reactions.

B. The final 2 min - Transfusion reactions are more likely to occur at the beginning of the transfusion rather than at the end.

C. The final 15 min - While it’s still important to monitor, reactions are most likely to be detected earlier in the infusion.

D. The first 15 min - Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for any signs of a reaction, such as fever, chills, rash, or difficulty breathing.

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Correct Answer is D

Explanation

A. Allergic: Allergic reactions typically involve symptoms such as hives, itching, and sometimes anaphylaxis, but not usually fever, chills, or hematuria (red-tinged urine).

B. Acute pain: Acute pain transfusion reaction is characterized by severe pain but not usually accompanied by fever, chills, or hematuria.

C. Febrile: Febrile reactions involve fever and chills but do not typically include red-tinged urine, which indicates hemolysis of red blood cells.

D. Hemolytic: A hemolytic transfusion reaction involves the destruction of red blood cells, leading to fever, chills, and red-tinged urine due to the presence of hemoglobin from lysed red cells in the urine.

A. increased heart rate B. Increase hematocrit C. increased blood pressure D. Increased temperature E. increased respiratory rate

Correct Answer is ["A","C","E"]

Explanation

A. Increased heart rate - Tachycardia can occur as the heart compensates for increased blood volume and the need to maintain effective circulation.

B. Increased hematocrit - Hematocrit usually decreases in fluid overload because the increased plasma volume dilutes the red blood cells.

C. Increased blood pressure - Excess fluid volume often leads to hypertension as there is more fluid for the heart to pump, increasing vascular resistance.

D. Increased temperature - Temperature is not directly affected by fluid overload; fever or changes in temperature are more likely related to infection or other inflammatory responses.

E. Increased respiratory rate - Fluid overload can cause pulmonary congestion and decreased oxygenation, leading to increased respiratory effort to maintain adequate oxygen levels.

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A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Correct Answer is D

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.]

Correct Answer is ["A","C","E"]

Explanation

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