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 D

Explanation

A. "Wash with plain soap and water." While cleanliness is important, plain soap can be drying and irritating. Gentle cleansing is better, using products that do not strip the skin of natural oils.

B. "Sit in the sun for 10 minutes per day." Sun exposure can exacerbate radiation dermatitis and should be avoided. The skin needs protection from additional UV damage.

C. "Apply moist heat." Moist heat can further irritate already sensitive skin and is not recommended for treating radiation-induced skin reactions.

D. "Apply hydrating lotions." Hydrating lotions help to soothe and moisturize the skin, promoting healing and alleviating dryness and scaling caused by radiation treatment. Use products specifically recommended for sensitive or radiated skin.

A. Keep family members aware of his condition. B. Talk with the client during wound care. C. Rotate nursing staff so he can have varied interactions. D. Assign assistive personnel to keep his room neat and clean.

Correct Answer is B

Explanation

A. Keep family members aware of his condition: While important, keeping family informed is not as directly impactful on the client’s emotional support as direct interaction with the client.

B. Talk with the client during wound care. Talking with the client during wound care can help to establish a trusting relationship, provide emotional support, and help the client cope with the pain and stress associated with burn treatment.

C. Rotate nursing staff so he can have varied interactions: Continuity of care is often more comforting to clients than having varied interactions.

D. Assign assistive personnel to keep his room neat and clean: This task is important for infection control but does not directly provide emotional support.

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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?

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Naxlex Comprehensive Predictor Exams

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