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 B
Explanation
A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not an escharotomy.
B. "Large incisions will be made in the eschar to improve circulation." An escharotomy involves making large incisions through the eschar (the tough, leathery scab or crust that forms over a severely burned area) to relieve pressure and improve blood flow to the affected area. This procedure is often necessary to prevent complications such as compartment syndrome and to enhance circulation in burn patients.
C. "The procedure involves placing the client into a shower and removing the dead tissue.": This describes debridement, not an escharotomy.
D. "Dead tissue will be non-surgically removed.": Non-surgical removal of dead tissue is debridement, not an escharotomy, which is a surgical procedure.
Correct Answer is A
Explanation
A. Heart rate: Adequate fluid resuscitation in burn patients helps to restore intravascular volume, improving circulation and perfusion. A decrease in heart rate indicates improved cardiac output and reduced compensatory tachycardia, suggesting adequate fluid replacement.
B. Weight: Fluid replacement can lead to an increase in weight due to the volume of fluids administered, not a decrease.
C. Urine output: Adequate fluid resuscitation typically increases urine output as renal perfusion improves.
D. Blood Pressure (BP): While BP can stabilize with adequate fluid resuscitation, it is not as direct an indicator as a decrease in heart rate in reflecting improved perfusion and hydration status.
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