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 A
Explanation
Choice A reason: Infection is the correct condition that the client is at increased risk for. Agranulocytosis is a severe decrease in the number of granulocytes, which are a type of white blood cell that fight infection. Propylthiouracil is an antithyroid drug that can cause agranulocytosis as a rare but serious side effect. The client with agranulocytosis is more susceptible to bacterial and fungal infections, and may present with fever, sore throat, mouth ulcers, and skin lesions.
Choice B reason: Excessive bleeding is not the correct condition that the client is at increased risk for. Agranulocytosis does not affect the platelets, which are the blood cells that help with clotting. Propylthiouracil does not cause bleeding disorders, although it may interact with anticoagulants and increase their effect.
Choice C reason: Hyperglycemia is not the correct condition that the client is at increased risk for. Agranulocytosis does not affect the insulin, which is the hormone that regulates blood glucose levels. Propylthiouracil does not cause hyperglycemia, although it may interfere with the metabolism of oral hypoglycemic agents and decrease their effect.
Choice D reason: Ecchymosis is not the correct condition that the client is at increased risk for. Ecchymosis is a bruise caused by bleeding under the skin. Agranulocytosis does not cause ecchymosis, as it does not affect the blood vessels or the platelets. Propylthiouracil does not cause ecchymosis, although it may increase the risk of skin rash and pruritus.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because dextrose 5% in 0.45% sodium chloride is a hypotonic solution that can cause hemolysis of the RBCs. It can also cause fluid shifts from the intravascular to the intracellular space, leading to edema and hypotension.
Choice B reason: This is correct because 0.9% sodium chloride is a isotonic solution that is compatible with blood products. It does not cause hemolysis or fluid shifts and maintains the osmotic pressure of the blood.
Choice C reason: This is incorrect because lactated Ringer's solution is a isotonic solution that contains electrolytes, such as potassium, calcium, and lactate, that can interfere with the blood products. It can also cause metabolic alkalosis due to the conversion of lactate to bicarbonate.
Choice D reason: This is incorrect because dextrose 5% in water is a hypotonic solution that can cause hemolysis of the RBCs. It can also cause fluid shifts from the intravascular to the intracellular space, leading to edema and hypotension.
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