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?

Allergic

Acute pain

Febrile

Hemolytic

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is B

Explanation

A. Instruct the client to dig their heels into the bed to push themselves upwards: This increases friction on the heels, which can lead to skin breakdown.

B. Assist the client with a trapeze to raise their body while staff assists with repositioning. Using a trapeze allows the client to lift themselves slightly off the bed, reducing the friction and shear forces that can cause skin injuries during repositioning.

C. Have two to three staff members pull the client up in bed when needed: This increases the risk of friction injuries, especially if the client is not lifted properly.

D. Elevate the head of the bed 90° for bedridden clients: High elevation of the bed can increase the risk of shear injuries due to sliding down in bed.

A. Slurred speech B. Confusion C. Pain D. Fatigue

Correct Answer is D

Explanation

A. Slurred speech - This is not a common symptom of iron deficiency anemia. It might suggest a neurological issue or other condition.

B. Confusion - While severe anemia might lead to confusion due to reduced oxygen delivery to the brain, it is not as common as fatigue and is usually seen in more advanced stages or in combination with other factors.

C. Pain - Pain is not a typical symptom of iron deficiency anemia unless it is related to other conditions like muscle fatigue from overall weakness.

D. Fatigue - Fatigue is a hallmark symptom of iron deficiency anemia due to the decreased ability of the blood to carry oxygen to tissues, leading to overall tiredness and lack of energy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?

Correct Answer is B

Explanation

A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

Correct Answer is D

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