A nurse is assessing a client who is receiving a unit of packed red blood cells. Which client statement suggests manifestation of an acute hemolytic reaction?
"I have sharp pain in my lower back."
"I am coughing a lot more now."
"I hear ringing in my ears."
"I feel needles poking in my feet."
The Correct Answer is A
A. Sharp pain in the lower back is a classic symptom of an acute hemolytic reaction, which can occur due to incompatible blood transfusions.
B. Coughing more could indicate a transfusion-related acute lung injury (TRALI) but is not a typical sign of an acute hemolytic reaction.
C. Ringing in the ears can occur with other conditions but is not a common sign of an acute hemolytic reaction.
D. Feeling needles poking in the feet is vague and not specifically associated with acute hemolytic reactions, which are characterized by more severe systemic symptoms.
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Correct Answer is B
Explanation
A. Distended jugular veins may indicate fluid overload or congestive heart failure, not an allergic reaction.
B. Generalized urticaria, or hives, is a classic sign of an allergic transfusion reaction, presenting as an itchy rash or welts on the skin.
C. Bilateral flank pain is more indicative of a hemolytic reaction, particularly due to kidney involvement, rather than an allergic reaction.
D. A blood pressure of 184/92 mm Hg may suggest hypertension or a reaction, but it is not specific to allergic transfusion reactions, which are characterized by skin symptoms like urticaria.
Correct Answer is ["B","C","D","E","F"]
Explanation
A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.
B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.
C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.
D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.
E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.
F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.
G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.