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 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.
Correct Answer is C
Explanation
A. "To place my leg under a heat lamp every 3 hours." Using a heat lamp can cause burns and uneven heating, which is not recommended for cellulitis.
B. "I will keep a heating pad on the calf of my right leg when I am lying down." Continuous heat application can cause burns and damage tissues, especially in clients with impaired sensation or circulation.
C. "I will wrap a warm, wet towel around my right calf every 4 hours." Using a warm, wet towel ensures that heat is evenly distributed and provides moist heat, which can help increase blood flow and promote healing in cellulitis.
D. "I will sit on the side of the tub and soak my right leg two times every day." Soaking the leg may not maintain consistent warmth and could also introduce the risk of infection if the water is not clean.
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