A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?

Jaw Pain

Urticaria

Distended neck veins

Hypotension

Answer and Explanation

The Correct Answer is D

A. Jaw Pain: Jaw pain is not typically associated with a hemolytic transfusion reaction. It may be more relevant in cardiac issues or in rare cases of referred pain, but it is not an indicator of transfusion reaction.

B. Urticaria: Urticaria (hives) is associated with allergic reactions, not specifically with hemolytic reactions. Acute hemolytic reactions are characterized more by systemic symptoms like hypotension and fever.

C. Distended neck veins: Distended neck veins suggest fluid overload or cardiac issues but are not characteristic of an acute hemolytic reaction.

D. Hypotension: Hypotension is a common sign of an acute hemolytic transfusion reaction. This occurs when the immune system attacks transfused red blood cells, leading to hemolysis, which can cause shock and a drop-in blood pressure.

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Correct Answer is D

Explanation

A. Heat relaxes the muscles and distracts the patient from the pain. While warmth can provide comfort, the main goal is to improve circulation rather than distraction.

B. Sickle cell crisis pain can be exacerbated with shivering. Although shivering may be uncomfortable, it is not the primary reason for using heat during a sickle cell crisis.

C. Heat promotes proper formation of red blood cells (RBCs) and prevents sickling. Heat does not affect RBC formation or prevent sickling. The condition of sickling is due to genetic factors, not temperature.

D. Heat increases circulation by preventing vasoconstriction. In sickle cell crisis, warmth helps prevent vasoconstriction, which can reduce blood flow to areas already compromised by sickled cells. Preventing vasoconstriction may help alleviate pain and improve circulation.

A. Malformed RBCs B. A deficiency in vitamin B12 C. An abundance of immature RBCS D. Destruction of RBCs

Correct Answer is D

Explanation

A. Malformed RBCs: Malformed RBCs are not caused by a transfusion reaction; they are generally a result of bone marrow abnormalities or genetic conditions.

B. A deficiency in vitamin B12: Vitamin B12 deficiency causes megaloblastic anemia, not hemolysis. It is unrelated to transfusion reactions.

C. An abundance of immature RBCs: Immature RBCs, or reticulocytes, can increase as a compensatory response to anemia but are not a direct result of a transfusion reaction. The primary issue is RBC destruction.

D. Destruction of RBCs: A hemolytic reaction occurs when the immune system attacks incompatible red blood cells, leading to their destruction.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?

Correct Answer is D

Explanation

The nurse is caring for a patient receiving treatment for a hemolytic reaction from a mismatched blood transfusion. The nurse understands that this the incompatible blood is causing what?

Correct Answer is D

Explanation

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