A nurse is monitoring a client who is receiving a transfusion of packed RBCs.
The client reports chills, headache, low-back pain, and a feeling of "tightness" in his chest.
The nurse should identify that the client has developed which of the following types of transfusion reactions?

Allergic.

Febrile nonhemolytic.

Acute hemolytic.

Bacterial.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Allergic transfusion reactions are characterized by symptoms such as hives, itching, and shortness of breath. While allergic reactions can cause discomfort, they do not typically present with the symptoms described in the scenario, such as chills, headache, low-back pain, and chest tightness.

Choice B rationale:

Febrile nonhemolytic transfusion reactions are characterized by fever and chills, but they do not usually cause headache, low-back pain, or chest tightness. These reactions occur due to antibodies against donor leukocytes or platelets.

Choice C rationale:

Acute hemolytic transfusion reactions occur when there is a mismatch in blood type between the donor and recipient, leading to rapid destruction of transfused red blood cells. This reaction can cause symptoms such as chills, fever, low-back pain, chest tightness, and hemoglobinuria (presence of hemoglobin in the urine) It is a medical emergency that requires immediate cessation of the transfusion, supportive care, and treatment for potential complications such as acute kidney injury.

Choice D rationale:

Bacterial transfusion reactions occur due to bacterial contamination of the blood product. These reactions can cause symptoms such as fever, chills, hypotension, and shock. While bacterial transfusion reactions can be serious, the symptoms described in the scenario, including headache and low-back pain, are not typically associated with this type of reaction.

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Correct Answer is B

Explanation

Choice B rationale:

Flumazenil is a selective antagonist for the benzodiazepine receptor and is used as an antidote for benzodiazepine toxicity. It competitively inhibits the effects of benzodiazepines by binding to the same receptor sites in the central nervous system. Flumazenil can rapidly reverse the sedative and respiratory-depressant effects of benzodiazepine overdose, making it the appropriate choice in this scenario.

Choice A rationale:

Atropine is an anticholinergic medication that is used to treat bradycardia and certain types of heart block. It has no specific antidote effects for benzodiazepine toxicity and would not be the appropriate choice in this situation.

Choice C rationale:

Activated charcoal is used in the management of certain types of poisonings by adsorbing the toxic substance in the gastrointestinal tract, preventing its absorption into the bloodstream. However, it is not effective for benzodiazepine toxicity, which primarily affects the central nervous system and not the gastrointestinal tract.

Choice D rationale:

Naloxone is an opioid receptor antagonist used to reverse opioid overdose. It has no specific effects on benzodiazepine toxicity and would not be the appropriate choice in this case.

A. Beneficence B. Autonomy C. Fidelity D. Veracity

Correct Answer is A

Explanation

A. Correct. Beneficence refers to the ethical principle of doing good and taking actions that promote the well-being and best interests of the client. Sitting with the client to provide comfort aligns with this principle.

B. Incorrect. Autonomy relates to respecting the client's right to make decisions about their own care and treatment.

C. Incorrect. Fidelity pertains to keeping promises and maintaining trust in the nurse-client relationship.

D. Incorrect. Veracity involves truthfulness and honesty in communication with clients, particularly in providing accurate information about their care and condition.

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A nurse is monitoring a client who is receiving a transfusion of packed RBCs.The client reports chills, headache, low-back pain, and a feeling of "tightness" in his chest.The nurse should identify that the client has developed which of the following types of transfusion reactions?

Nursing Test Bank

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Correct Answer is B

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A nurse is monitoring a client who is receiving a transfusion of packed RBCs.
The client reports chills, headache, low-back pain, and a feeling of "tightness" in his chest.
The nurse should identify that the client has developed which of the following types of transfusion reactions?