A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing a hemolytic reaction?
Vomiting
Flushing
Dyspnea
Hypotension
The Correct Answer is D
Choice A reason: Vomiting is not a specific sign of a hemolytic reaction, as it can be caused by many other factors, such as anesthesia, infection, or medication. Vomiting may occur in other types of transfusion reactions, such as allergic or febrile reactions, but it is not indicative of hemolysis.
Choice B reason: Flushing is not a specific sign of a hemolytic reaction, as it can be caused by many other factors, such as fever, infection, or medication. Flushing may occur in other types of transfusion reactions, such as allergic or febrile reactions, but it is not indicative of hemolysis.
Choice C reason: Dyspnea is often linked with transfusion-associated circulatory overload (TACO) or transfusion-related acute lung injury (TRALI). Both of these conditions primarily impact the respiratory system, leading to difficulty breathing. Although respiratory symptoms can accompany severe reactions, dyspnea is not a key feature of a hemolytic reaction.
Choice D reason: Hypotension is a significant indicator of an acute hemolytic reaction. When the recipient’s immune system attacks the donor red blood cells, widespread inflammatory and immune responses occur, leading to vascular collapse. This can manifest as sudden low blood pressure, which is life-threatening if not recognized and treated immediately. Alongside other findings such as fever, chills, flank pain, and hemoglobinuria, hypotension is a classic hallmark of hemolysis during transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Migraines are not a contraindication for propranolol. In fact, propranolol is used as a prophylactic treatment for migraines, as it reduces the frequency and severity of migraine attacks.
Choice B reason: Glaucoma is not a contraindication for propranolol. Propranolol does not affect the intraocular pressure or the drainage of aqueous humor in the eye.
Choice C reason: Asthma is a contraindication for propranolol. Propranolol is a nonselective beta-blocker, which means it blocks both beta-1 and beta-2 receptors in the body. Beta-2 receptors are found in the bronchial smooth muscle, and when they are blocked, they cause bronchoconstriction and increased airway resistance. This can worsen the symptoms of asthma and cause a life-threatening asthma attack.
Choice D reason: Depression is not a contraindication for propranolol. Propranolol does not cause depression, although it may cause some side effects such as fatigue, insomnia, and sexual dysfunction. However, these side effects are usually mild and reversible.
Correct Answer is B
Explanation
Choice A reason: Hematocrit 45% is not the correct data. Hematocrit is the percentage of red blood cells in the blood. The normal range for hematocrit is 37% to 47% for women and 42% to 52% for men. Hematocrit 45% is within the normal range and does not indicate any abnormality related to heparin therapy. Heparin does not affect the production or destruction of red blood cells.
Choice B reason: Platelets 74,000/mm3 is the correct data. Platelets are the blood cells that are responsible for clotting and preventing bleeding. The normal range for platelets is 150,000 to 400,000/mm3. Platelets 74,000/mm3 is below the normal range and indicates thrombocytopenia, which is a low platelet count. Thrombocytopenia is a serious complication of heparin therapy that can cause bleeding, bruising, and petechiae. The nurse should report this finding to the provider immediately and stop the heparin infusion.
Choice C reason: Partial thromboplastin time (PTT) 65 seconds is not the correct data. PTT is a blood test that measures the time it takes for the blood to clot. The normal range for PTT is 25 to 35 seconds. PTT 65 seconds is above the normal range and indicates that the blood is taking longer to clot. This is an expected effect of heparin therapy, as heparin is an anticoagulant that inhibits the formation of blood clots. The nurse should monitor the PTT and adjust the heparin dose according to the provider's orders and the protocol.
Choice D reason: White blood cell count 8,000/mm3 is not the correct data. White blood cells are the blood cells that are involved in the immune system and fight infections. The normal range for white blood cells is 4,500 to 11,000/mm3. White blood cell count 8,000/mm3 is within the normal range and does not indicate any abnormality related to heparin therapy. Heparin does not affect the production or function of white blood cells.
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