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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A teenage boy is the correct answer. The HPV vaccine is recommended for males and females starting at age 11 or 12, but it is most effective when given before any sexual activity. The vaccine can be administered through age 26 for individuals who were not vaccinated at the appropriate age.
B. An older adult woman is not typically recommended for the HPV vaccine. The vaccine is most effective when given before exposure to the virus, typically in preadolescent girls and boys. Women over the age of 26 may not benefit as much from the vaccine.
C. A preschool-age girl is unlikely to receive the HPV vaccine at this age, as it is usually given starting at age 11 or 12, ideally before the onset of sexual activity.
D. A middle adult man may still receive the HPV vaccine if not previously vaccinated, but it is primarily recommended for individuals under age 26.
Correct Answer is D
Explanation
A. Using hot water to wash hands is incorrect. Hot water can cause skin irritation and is not necessary for effective hand hygiene. The water temperature should be comfortable for the person washing their hands, whether it is warm or cool.
B. Applying friction to hands for 10 seconds is incorrect. Hand hygiene should be done for at least 20 seconds, not just 10 seconds, to effectively remove contaminants.
C. Drying hands starting from forearm to fingers is incorrect. Hands should be dried starting from the fingers to the forearms to avoid contamination from dripping water on the hands after washing. The goal is to maintain clean hands throughout the drying process.
D. Interlacing the fingers while rubbing hands together is correct. Interlacing the fingers and rubbing them together ensures that all surfaces of the hands, including between the fingers, are properly cleaned. This method is recommended in the CDC hand hygiene guidelines for thorough washing.
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