A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic. reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
Hemolytic
Allergic
Febrile
Bacterial
The Correct Answer is A
A. Hemolytic: Acute hemolytic transfusion reactions can occur quickly after starting a transfusion and present with symptoms such as fever, chills, headache, low back pain, tachycardia, and apprehension. It is a serious reaction caused by the destruction of transfused red blood cells.
B. Allergic: Allergic reactions to blood transfusions typically present with hives, itching, and anaphylaxis, not low back pain or tachycardia.
C. Febrile: Febrile reactions involve fever and chills but not typically headache or back pain.
D. Bacterial: Bacterial contamination of blood can cause fever and chills, but not specifically the symptoms of headache and low back pain described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Heart rate: Adequate fluid resuscitation in burn patients helps to restore intravascular volume, improving circulation and perfusion. A decrease in heart rate indicates improved cardiac output and reduced compensatory tachycardia, suggesting adequate fluid replacement.
B. Weight: Fluid replacement can lead to an increase in weight due to the volume of fluids administered, not a decrease.
C. Urine output: Adequate fluid resuscitation typically increases urine output as renal perfusion improves.
D. Blood Pressure (BP): While BP can stabilize with adequate fluid resuscitation, it is not as direct an indicator as a decrease in heart rate in reflecting improved perfusion and hydration status.
Correct Answer is A
Explanation
A. Endolymph fluid provides protection to the structures of the inner ear. - Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance.
B. Sanguineous fluid provides protection to the structures of the inner ear - Sanguineous fluid refers to blood or fluid containing blood. It is not present in the inner ear.
C. Aqueous humor provides protection to the structures of the inner ear - Aqueous humor is the fluid found in the eye, not the ear.
D. Vitreous humor provides protection to the structures of the inner ear - Vitreous humor is found in the eye, not the ear.
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