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:
Taking an antacid 30 minutes before taking ciprofloxacin is not necessary. Ciprofloxacin should generally be taken on an empty stomach, either 1-2 hours before or 2 hours after meals, but antacids containing aluminium, magnesium, or calcium can interfere with its absorption.
Choice B Reason:
Drinking 2 to 3 L of fluids daily is correct. For a client with chronic urinary tract infections who is taking ciprofloxacin, the nurse should instruct the client to increase fluid intake to maintain good urine flow and help flush out bacteria from the urinary system. Adequate hydration can contribute to preventing and managing urinary tract infections.
Choice C Reason:
Taking a laxative to prevent constipation is not directly related to ciprofloxacin use. While constipation can be a side effect of some medications, it is not a primary concern with ciprofloxacin.
Choice D Reason:
Monitoring heart rate is not a typical instruction related to ciprofloxacin use. While ciprofloxacin can have potential effects on heart rhythm (especially in high doses), this is not a common aspect of its use and does not typically require daily monitoring of heart rate.
Correct Answer is C
Explanation
Choice A reason:
Hct 42% is not appropriate. This haematocrit value is within the normal range (usually around 36-46% for females and 38-50% for males).
Choice B reason:
WBC count 8,000/mm3 is not appropriate. This white blood cell count is within the normal range (typically around 4,500 to 11,000/mm3).
Choice C reason:
INR of 1.6 An INR (International Normalized Ratio) of 1.6 indicates that the client's blood clotting time is prolonged, which means that they might have a decreased ability to form blood clots. This could pose a significant risk during surgery, as proper blood clotting is important to prevent excessive bleeding. The surgeon needs to be aware of this result to determine if any adjustments to the surgical plan or preoperative medications are necessary to ensure the client's safety.
Choice D reason:
Platelets 95,000/mm3 is not appropriate This platelet count is slightly lower than the normal range (typically around 150,000 to 450,000/mm3), but it might not be low enough to be immediately concerning, especially if the client doesn't have a history of bleeding disorders. However, it's still important for the surgical team to be aware of this value.
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