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 C

Explanation

A. Canned black beans are a good source of fiber and protein, but they are not specifically recommended for hypertension.
B. Cheese is often high in saturated fat and sodium, which can contribute to hypertension and cardiovascular risk.
C. Correct. Fish, especially fatty fish like salmon, mackerel, and trout, are rich in omega-3 fatty acids, which have been associated with cardiovascular benefits, including reducing blood pressure.
D. Red meat is often high in saturated fat and is not typically recommended for individuals with hypertension.

A. Place a towel roll under the client's neck. B. Position a pillow under the client's knees. C. Apply an orthotic to the client's foot. D. Align a trochanter wedge between the client's legs.

Correct Answer is C

Explanation

A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.

B. Incorrect. This can promote flexion of the knees, which may actually contribute to knee flexion contractures over time. While it might be comfortable for the client, it's not a preventive measure against contractures.

C. Correct. Orthotics can help maintain proper alignment of the foot and ankle, preventing foot drop and other related contractures. They are designed to support joints and muscles, minimizing the risk of stiffness and contracture formation.

D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.

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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?

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Correct Answer is C

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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?