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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 4 hr - The total infusion time for packed RBCs should not exceed 4 hours. Infusing beyond this period increases the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications.
B. 2 hr - While blood can be infused in 2 hours for some patients, especially in non-emergent situations, the standard maximum time allowed is 4 hours to prevent complications.
C. 8 hr - Infusing blood over 8 hours is too long and increases the risk of bacterial contamination and decreased efficacy of the blood product.
D. 6 hr - Similar to 8 hours, a 6-hour infusion time is too lengthy and poses significant risks for bacterial growth and sepsis.
Correct Answer is ["A","C","E"]
Explanation
A. D-dimer blood test - A D-dimer test measures clot breakdown products in the blood. Elevated levels suggest the presence of an abnormal blood clot, such as in PE, although it is not specific.
B. Complete blood count (CBC) - A CBC is not typically used to diagnose PE. It may be ordered to check for other conditions or as part of the overall health assessment, but it doesn't confirm PE.
C. CT scan - A CT pulmonary angiography is the gold standard for diagnosing PE. It provides detailed images of the blood vessels in the lungs.
D. Chest x-ray - A chest x-ray is not diagnostic for PE. It is often performed to rule out other causes of the client’s symptoms (e.g., pneumonia, pneumothorax) but does not confirm the presence of a pulmonary embolism.
E. Lung ventilation and perfusion scan (VQ scan)
A VQ scan is another diagnostic tool for PE, especially in clients who cannot tolerate contrast dye required for CT scans. It assesses the ventilation and perfusion of the lungs and identifies mismatches suggestive of PE.
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