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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:

Measuring the client's blood pressure is appropriate. Assessing the client's blood pressure is a crucial initial step to determine the client's perfusion status and the impact of the bradycardia on their circulation. Sinus bradycardia can result in decreased cardiac output and compromised blood flow to various organs. Measuring the blood pressure helps the nurse evaluate the severity of the bradycardia and its potential effects on the client's overall condition.

Choice B Reason:

Administering atropine to the client is inappropriate. Atropine is a medication that can be used to increase heart rate in bradycardic situations. However, assessing blood pressure comes first to ensure that the blood pressure isn't critically low before administering medications.

Choice C reason:

Initiating IV fluid therapy for the client is inappropriate. Fluid therapy might be necessary to improve perfusion in certain cases, but assessing blood pressure should be done first to guide treatment decisions.

Choice D Reason:

Preparing the client for temporary pacing is inappropriate Temporary pacing might be required in severe cases of bradycardia, but again, assessing blood pressure takes priority to determine the urgency of intervention.

A. Take an antacid 30 min before taking the medication. B. Drink 2 to 3 L of fluids daily. C. Take a laxative to prevent constipation D. Monitor heart rate once daily

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.

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A nurse is monitoring a client who is receiving 2 units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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