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

Bradycardia

Hypertension

Chills

Back pain

Answer and Explanation

The Correct Answer is D

Back pain is a common symptom of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks and destroys the donor's red blood cells. Other symptoms include fever, chills, dyspnea, chest pain, hypotension, tachycardia, hemoglobinuria, and jaundice. A hemolytic transfusion reaction is a medical emergency that requires immediate intervention.

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Correct Answer is A

Explanation

The nurse should measure the client's blood pressure first, as sinus bradycardia can cause hypotension and decreased perfusion to vital organs. The nurse should assess the client's hemodynamic status and symptoms before initiating any interventions that may affect their heart rate or rhythm. The other options may be appropriate depending on the severity of the bradycardia and its underlying cause, but they are not the first priority.

A. Initiate venous access with a 21-gauge needle. B. Use Y tubing with 0.9% sodium chloride when administering the transfusion. C. Administer the unit of packed RBCs over 1 hr. D. Obtain the client's first set of vital signs 1 hr after initiating the transfusion.

Correct Answer is A

Explanation

Practice standards indicateblood should be infused through a 20-gauge or larger catheter to prevent hemolysis [destruction] of red blood cells. Y tubing with 0.9% sodium chloride is used to administer blood products is not necessary.A unit of packed RBCs should be administered over 2 to 4 hours, unless otherwise ordered by the provider, to reduce the risk of fluid overload and transfusion reactions . The client's vital signs should be obtained before, during (15 minutes after starting and every hour thereafter), and after the transfusion to monitor for any signs of adverse reactions.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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