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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: A low-protein diet is not recommended. Clients with preeclampsia may benefit from adequate protein intake to support vascular integrity and fetal growth.

Choice B reason: Fetal heart rate should be monitored more frequently than twice daily in severe preeclampsia due to the risk of placental insufficiency and fetal compromise.

Choice C reason: Raising the side rails is a safety measure to prevent injury in case of seizures, which are a risk in severe preeclampsia. It is a standard precaution.

Choice D reason: Ambulation may increase the risk of complications. Bed rest or limited activity is often recommended to reduce blood pressure and prevent seizures.

A. Limit each of the client's visitors to 2 hours per day B. Instruct visitors to stay 1 meter (3.3 feet) away from the client C. Strain the client's urine D. Attach a dosimeter to the client's gown

Correct Answer is B

Explanation

Choice A reason: Visitor time should be limited, but the specific duration depends on institutional policy. The priority is maintaining distance, not strictly timing.

Choice B reason: Maintaining a distance of at least 1 meter from the client helps reduce radiation exposure to others. This is a key safety measure during brachytherapy.

Choice C reason: Straining urine is not necessary for low-dose prostate implants unless seeds are expected to be expelled, which is rare.

Choice D reason: The dosimeter should be worn by staff, not attached to the client’s gown. It monitors staff exposure to radiation.

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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 their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

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