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 their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?
Acute hemolytic
Allergic
Febrile nonhemolytic
Bacterial
The Correct Answer is A
Choice A reason: Acute hemolytic reaction is the most severe and potentially life-threatening transfusion reaction. It occurs due to ABO incompatibility and presents with symptoms such as chills, fever, low-back pain, chest tightness, and hemoglobinuria. Immediate cessation of the transfusion and emergency intervention are required.
Choice B reason: Allergic reactions typically present with urticaria, itching, and mild respiratory symptoms. They do not usually involve chest tightness or back pain.
Choice C reason: Febrile nonhemolytic reactions are common and usually present with fever and chills but lack the severe systemic symptoms like chest tightness and back pain.
Choice D reason: Bacterial contamination of blood products can cause fever and hypotension, but it is less likely to present with the specific constellation of symptoms described here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Nonstress testing evaluates fetal well-being by monitoring heart rate patterns in response to movement. It does not assess genetic abnormalities.
Choice B reason: Clients are encouraged to eat before the test to stimulate fetal movement. Fasting is not required.
Choice C reason: Oxytocin is used in contraction stress testing, not nonstress testing. The two tests assess different aspects of fetal health.
Choice D reason: During a nonstress test, the client pushes a button when fetal movement is felt. This helps correlate movement with heart rate accelerations.
Correct Answer is D
Explanation
Choice A reason: Whole wheat pasta contains gluten, which must be strictly avoided in celiac disease. Even small amounts can trigger intestinal damage.
Choice B reason: Rye bread contains gluten, and processed meats like bologna may contain hidden gluten additives. This combination is inappropriate for a child with celiac disease.
Choice C reason: Barley is a gluten-containing grain and is contraindicated in celiac disease. Even in small amounts, it can provoke symptoms and intestinal inflammation.
Choice D reason: Corn tortillas and black beans are naturally gluten-free and safe for children with celiac disease. They provide fiber and protein without triggering symptoms.
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