A nurse is caring for a patient who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the patient is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
Allergic
Hemolytic
Acute pain
Febrile
The Correct Answer is B
A. Allergic – An allergic reaction typically presents with itching, rash, and wheezing rather than fever, chills, and hematuria.
B. Hemolytic – Correct Answer. A hemolytic reaction occurs when the immune system attacks transfused red blood cells due to incompatibility. Symptoms include fever, chills, hypotension, back pain, and hematuria (red-tinged urine). This is a medical emergency requiring immediate intervention.
C. Acute pain – Acute pain transfusion reaction is rare and mainly presents with severe chest, back, and joint pain, without fever or hematuria.
D. Febrile – Febrile reactions cause fever and chills but do not typically cause hematuria, which is indicative of hemolysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Leave the television on as a distraction – Noise and distractions can increase anxiety and confusion in some patients.
B. Limit patient physical activity – Regular exercise is essential to maintain mobility and prevent muscle atrophy.
C. Provide patient supervision – Clients with Parkinson’s disease are at high risk for falls due to muscle rigidity and balance difficulties. Supervision ensures safety and helps prevent injuries.
D. Speak loudly to the patient – Parkinson’s does not typically cause hearing loss. Speaking clearly and slowly is more effective than speaking loudly.
Correct Answer is B
Explanation
A. Impaired immunity. – Incorrect. While anemia may weaken overall health, hemoglobin levels of 10 g/dL do not significantly affect immune function.
B. Hypoxia. – Correct Answer. Hemoglobin carries oxygen in the blood, and low levels can lead to decreased oxygen delivery to tissues, causing hypoxia.
C. Fluid retention. – Incorrect. Anemia does not directly cause fluid retention.
D. Prolonged bleeding. – Incorrect. While severe anemia can be associated with bleeding disorders, a hemoglobin level of 10 g/dL does not significantly impair clotting.
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