A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
Anaphylactic
Acute hemolytic
Febrile
Circulatory overload
The Correct Answer is A
A. An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.
B. An acute hemolytic reaction is incorrect. This reaction occurs when the recipient's immune system attacks incompatible donor red blood cells, leading to symptoms such as fever, chills, flank pain, hypotension, and hemoglobinuria. Urticaria and wheezing are not characteristic symptoms of this reaction.
C. A febrile reaction is incorrect. Febrile reactions are the most common type of transfusion reaction and are typically characterized by fever, chills, and headache, rather than urticaria or wheezing.
D. Circulatory overload is incorrect. This reaction occurs when too much fluid is infused too quickly, leading to dyspnea, hypertension, and pulmonary edema. While respiratory distress can occur, it is not accompanied by urticaria, which is specific to an allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “This medication will darken the color of my eyes.” is incorrect. Timolol is a nonselective beta-blocker used to reduce intraocular pressure in glaucoma. It does not typically cause eye color changes.
B. "I should check my heart rate while taking this medication." is correct. Timolol can cause systemic side effects such as bradycardia, so the client should monitor their heart rate while taking the medication.
C. "I should take a zinc supplement while taking this medication." is incorrect. Zinc supplementation is not related to the use of timolol.
D. “This medication will dilate my eyes." is incorrect. Timolol works by decreasing aqueous humor production, reducing intraocular pressure, and does not cause dilation of the eyes. Medications like atropine are used for pupil dilation.
Correct Answer is B
Explanation
A. "Replace the ear molds once per year" is incorrect. Ear molds should be checked regularly for wear and tear, but they should be replaced as needed rather than on a fixed schedule like once a year.
B. "Clean the hearing aid with a soft cloth" is correct. Cleaning the hearing aid with a soft cloth helps to maintain the device, removing dirt and debris without damaging the electronics. It is important to avoid using harsh chemicals or abrasive materials that could harm the hearing aid.
C. "Disinfect the hearing aid with isopropyl alcohol" is incorrect. Isopropyl alcohol is too harsh for cleaning hearing aids and can damage the components. The hearing aid should only be cleaned with appropriate methods, such as a dry cloth or cleaning brush.
D. "Change the battery once per month" is incorrect. The battery should be checked more frequently, as it typically needs to be replaced more often (e.g., every 7-10 days), depending on usage. Changing it once a month may not ensure optimal performance.
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