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 C
Explanation
A. Anorexia and malnutrition - While these may occur due to chemotherapy, they are not directly caused by myelosuppression.
B. Diarrhea and dehydration - These symptoms might be side effects of chemotherapy but are not specific to myelosuppression.
C. Bleeding from the gums - Myelosuppression can lead to thrombocytopenia (low platelet count), increasing the risk of bleeding, including from gums and other mucous membranes.
D. Full body alopecia - Alopecia is a common side effect of chemotherapy but is not related to myelosuppression.
Correct Answer is C
Explanation
A. "To place my leg under a heat lamp every 3 hours." Using a heat lamp can cause burns and uneven heating, which is not recommended for cellulitis.
B. "I will keep a heating pad on the calf of my right leg when I am lying down." Continuous heat application can cause burns and damage tissues, especially in clients with impaired sensation or circulation.
C. "I will wrap a warm, wet towel around my right calf every 4 hours." Using a warm, wet towel ensures that heat is evenly distributed and provides moist heat, which can help increase blood flow and promote healing in cellulitis.
D. "I will sit on the side of the tub and soak my right leg two times every day." Soaking the leg may not maintain consistent warmth and could also introduce the risk of infection if the water is not clean.
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