A nurse is collecting data on a patient who is receiving a unit of PRBCs.
Which of the following symptoms is a sign of an allergic transfusion reaction?
Wheezing
Flank pain
Elevated blood pressure
Distended neck veins
Answer and explanation The
The Correct Answer is A
Choice A rationale:
Wheezing is a common symptom of an allergic transfusion reaction. An allergic transfusion reaction occurs when the recipient’s immune system reacts to foreign proteins or allergens in the donor’s blood. Symptoms of an allergic reaction can range from mild to severe, and they typically include skin reactions such as hives and itching, as well as respiratory symptoms like wheezing. In severe cases, the reaction can cause difficulty breathing.
Choice B rationale:
Flank pain is not typically associated with an allergic transfusion reaction. It is more commonly a symptom of conditions affecting the kidneys or urinary tract. While flank pain can occur in a hemolytic transfusion reaction due to the rapid destruction of red blood cells, it is not a symptom of an allergic reaction.
Choice C rationale:
Elevated blood pressure is not a typical symptom of an allergic transfusion reaction. Allergic reactions more commonly cause symptoms such as hives, itching, and respiratory symptoms like wheezing. In severe cases, an allergic reaction can actually lead to a drop in blood pressure.
Choice D rationale:
Distended neck veins are not a typical symptom of an allergic transfusion reaction. They are more commonly associated with conditions that cause increased pressure in the right side of the heart. While distended neck veins can occur in a transfusion reaction due to fluid overload, they are not a symptom of an allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,C,A,D
Explanation
B. Confirm the patient’s identity by checking their wristband.
Explanation: Always begin by confirming the patient’s identity to ensure the correct treatment is given to the right patient. This step is critical in maintaining patient safety and is a standard part of care.
C. Provide privacy for the patient by closing the curtains.
Explanation: After confirming identity, ensuring privacy is important for the patient’s comfort and dignity. This is especially relevant for procedures like enemas, which may cause embarrassment or discomfort.
A. Assisting the patient into the Sims’ position.
Explanation: The Sims' position, where the patient lies on their left side with the right knee flexed, is the preferred position for enema administration. This position allows for easy insertion of the enema tube and ensures that gravity helps the solution flow into the rectum and colon.
D. Insert the tip of the enema tubing into the patient’s rectum.
Explanation: Once the patient is in the correct position, the nurse carefully inserts the enema tubing into the rectum, following proper technique to ensure patient safety and comfort.
Correct Answer is A
Explanation
Choice A rationale:
Urinary retention is a condition where the bladder doesn’t empty all the way or at all when you urinate. This can lead to leakage of urine, as the bladder is overfilled and may result in small amounts of urine escaping. This symptom is often associated with urinary retention and is therefore a likely finding in a client with this condition.
Choice B rationale:
Dark-colored urine is not typically a direct symptom of urinary retention. It can be a sign of dehydration, certain dietary factors, or a side effect of some medications. While it’s possible for a person with urinary retention to have dark-colored urine, it’s not a specific or direct symptom of the condition.
Cloudy urine can be a sign of a urinary tract infection (UTI), which can occur as a complication of urinary retention. However, it’s not a direct symptom of urinary retention itself. A nurse would not necessarily expect to see cloudy urine in a client with urinary retention unless a UTI or another complication was present.
Choice D rationale:
Blood in the urine, or hematuria, is not a typical symptom of urinary retention. It can be a sign of various conditions, including UTIs, kidney stones, or more serious conditions like bladder or kidney disease. While it’s possible for a person with urinary retention to have blood in their urine, it’s not a direct symptom of the condition.
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