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 C
Explanation
Choice A reason: Weight gain is more commonly associated with hypothyroidism or inadequate dosing of levothyroxine. Thyrotoxicosis typically causes weight loss due to increased metabolic activity.
Choice B reason: Bradycardia is a sign of hypothyroidism. Thyrotoxicosis causes tachycardia and palpitations due to increased sympathetic stimulation.
Choice C reason: Fever can be a sign of thyrotoxicosis, especially in severe cases like thyroid storm. It reflects the hypermetabolic state and systemic stress.
Choice D reason: Drowsiness is not a typical symptom of thyrotoxicosis. Clients may instead experience restlessness, insomnia, or anxiety.
Correct Answer is B
Explanation
Choice A reason: Rewrapping the bandage in a circular pattern can impair circulation and increase the risk of edema. A figure-eight or diagonal wrapping technique is preferred to promote venous return and shape the residual limb for prosthesis fitting.
Choice B reason: Using an overbed trapeze allows the client to reposition independently, which promotes mobility, prevents complications such as pressure injuries, and supports postoperative recovery. It also reduces strain on the surgical site.
Choice C reason: An air mattress may be used for clients at high risk of pressure injuries, but it is not a standard intervention for all postoperative amputation clients unless additional risk factors are present.
Choice D reason: Turning every 4 hours is insufficient for postoperative care. Standard practice recommends repositioning every 2 hours to prevent pressure ulcers and promote circulation.
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