A nurse is monitoring a client who is receiving 2 units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?
Bradycardia
Hypertension
Back pain
Chills
The Correct Answer is C
Choice A Reason:
Bradycardia - Bradycardia is not a typical symptom of a haemolytic transfusion reaction.
Choice B Reason;
Hypertension - Hypertension is not a common manifestation of a haemolytic transfusion reaction.
Choice C Reason:
Back pain A haemolytic transfusion reaction is a severe and potentially life-threatening complication that can occur when the immune system reacts against the transfused red blood cells. Back pain is a classic symptom of a haemolytic transfusion reaction. It is often accompanied by other symptoms such as fever, chills, chest pain, dyspnoea, nausea, vomiting, haematuria, and hemoglobinuria (presence of haemoglobin in the urine).
Choice D Reason:
Chills - Chills can occur in various types of transfusion reactions, including haemolytic reactions, but they are not as specific as back pain for indicating a haemolytic transfusion reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Administer a sedative medication is incorrect. Administering a sedative can help the client feel more comfortable during the procedure, but ensuring allergy safety comes first.
Choice B Reason:
Determine whether the client has an allergy to local anaesthetics is correct. The priority intervention for the nurse is to determine whether the client has an allergy to local anaesthetics. Local anaesthetics are typically used to numb the area before a thoracentesis, and ensuring the safety of the client is essential. An allergy to local anaesthetics can result in serious adverse reactions, so it's crucial to identify any allergies before proceeding with the procedure.
Choice C Reason:
Describe the sensations the client will feel during the procedure is incorrect. Providing information about the sensations is important for client education and comfort, but verifying allergies is more critical.
Choice D Reason:
Reinforce the importance of lying still during the procedure - Encouraging the client to lie still is important for the procedure's success and client safety, but confirming allergies takes priority.
Correct Answer is B
Explanation
Choice A Reason:
Magnesium - While magnesium levels can affect cardiac function, hypomagnesemia is not a primary risk factor for digoxin toxicity.
Choice B Reason:
Potassium. An imbalance of potassium can increase the risk of digoxin toxicity. Hypokalaemia (low potassium levels) enhances the binding of digoxin to its target receptors in the heart, leading to an increased risk of digoxin toxicity. It's essential to monitor potassium levels in clients taking digoxin, as maintaining a stable potassium level helps prevent adverse effects associated with digoxin therapy.
Choice C Reason:
Phosphatase - Phosphate levels are not commonly associated with an increased risk of digoxin toxicity.
Choice D Reason:
Calcium - Calcium levels can affect cardiac function, but they are not a primary factor in the development of digoxin toxicity.
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