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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Leaving a nasogastric tube clamped after administering oral medication is a mistake, but it may not necessarily be considered malpractice if it doesn't result in harm or negligence.
B. Incorrect. Placing a yellow bracelet on a client at risk for falls is a safety measure, and it's not an example of malpractice.
C. Correct. Administering potassium via IV bolus can be dangerous and is considered malpractice if not done properly. Rapid administration of potassium via IV bolus can lead to serious cardiac complications.
D. Incorrect. Documenting communication with a provider in the progress notes of the client's medical record is a standard practice and not an example of malpractice.
Correct Answer is A
Explanation
A. Correct. Participating in range-of-motion exercises helps prevent circulation problems and joint stiffness that can result from prolonged immobility after surgery.
B. Incorrect. While elevating the knees can help reduce strain on the lower back, this might not specifically promote circulation.
C. Incorrect. Prolonged bed rest can lead to decreased circulation and increased risk of complications such as deep vein thrombosis (DVT).
D. Incorrect. While using an incentive spirometer is important for preventing respiratory complications, it might not specifically address circulation issues.
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