The nurse is caring for a patient receiving packed red blood cells which started at 11:30 AM. The patient's vital signs and assessment findings are provided in the table below. What type of transfusion reaction will the nurse identify that the patient is experiencing?

Acute hemolytic

Allergic

Anaphylactic

Circulatory overload

Answer and Explanation

The Correct Answer is B

Choice A reason: Acute hemolytic reactions are severe and typically present with symptoms such as fever, chills, flank pain, hemoglobinuria, and shock. The patient's mild symptoms of itching and a localized rash do not match the severe presentation of an acute hemolytic reaction.

Choice B reason: Allergic reactions to blood transfusions are common and usually present with symptoms such as itching, hives, and localized rash. The patient's vital signs and physical assessment showing mild itching and a rash on the arms are consistent with an allergic reaction.

Choice C reason: Anaphylactic reactions are severe allergic reactions that involve respiratory distress, hypotension, and shock. The patient's mild symptoms do not indicate an anaphylactic reaction.

Choice D reason: Circulatory overload presents with symptoms such as dyspnea, orthopnea, hypertension, and pulmonary edema. The patient's symptoms of itching and a rash do not align with circulatory overload.

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Correct Answer is B

Explanation

Choice A reason: Encouraging the patient to engage in moderate exercise to improve circulation is not appropriate during a sickle cell crisis. Exercise can increase oxygen demand and exacerbate the crisis. Rest and avoiding strenuous activities are recommended.

Choice B reason: Applying warm compresses to the painful areas can help reduce discomfort and improve circulation. Warmth helps relax muscles and dilate blood vessels, providing relief during a sickle cell crisis.

Choice C reason: Suggesting the patient drink caffeinated beverages to stay alert and energized is not appropriate. Caffeine can cause dehydration, which can worsen the sickling of red blood cells. Maintaining hydration with water and non-caffeinated beverages is essential.

Choice D reason: Recommending cold showers to help reduce pain and swelling is incorrect. Cold can cause vasoconstriction, which can worsen pain and reduce blood flow to affected areas. Warm compresses are preferred.

A. "I can eat any foods I want before dialysis as long as I don't drink too much fluid." B. "I need to report any unusual changes in my access site, like redness or swelling." C. "I will need to check my blood pressure regularly to monitor for changes during dialysis." D. "I should contact my healthcare provider if I notice swelling in my hands, feet, or ankles." E. "I understand that hemodialysis will permanently cure my kidney disease."

Correct Answer is ["A","E"]

Explanation

Choice A reason: Eating any foods before dialysis as long as fluid intake is limited is incorrect. Patients undergoing hemodialysis need to follow specific dietary restrictions to manage electrolyte balance and prevent complications. A renal diet typically limits potassium, phosphorus, and sodium intake, in addition to fluid restrictions.

Choice B reason: Reporting any unusual changes in the access site, like redness or swelling, is correct. Changes at the access site can indicate infection or other complications and require immediate attention.

Choice C reason: Checking blood pressure regularly to monitor for changes during dialysis is correct. Blood pressure monitoring is essential during dialysis to detect hypotension or hypertension and adjust treatment accordingly.

Choice D reason: Contacting the healthcare provider if swelling in hands, feet, or ankles is noticed is correct. Swelling can indicate fluid overload or other complications that need to be addressed.

Choice E reason: Understanding that hemodialysis will permanently cure kidney disease is incorrect. Hemodialysis is a treatment that replaces kidney function but does not cure kidney disease. It manages symptoms and removes waste products from the blood.

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The nurse is caring for a patient receiving packed red blood cells which started at 11:30 AM. The patient's vital signs and assessment findings are provided in the table below. What type of transfusion reaction will the nurse identify that the patient is experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a patient who is experiencing a sickle cell crisis about non-pharmacological interventions to help alleviate symptoms. Which of the following interventions will the nurse recommend?

Correct Answer is B

Explanation

The nurse is teaching a patient who is scheduled for hemodialysis about the process and potential complications. Which of the following statements by the patient indicates to the nurse the need for further teaching? (Select All That Apply)

Correct Answer is ["A","E"]

Explanation

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