A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?
Pulmonary congestion
Urticaria
Vomiting
Low back pain
The Correct Answer is D
A. Pulmonary congestion: Pulmonary congestion is associated more with fluid overload or transfusion-associated circulatory overload (TACO), not an acute hemolytic reaction.
B. Urticaria: Urticaria (hives) is more typical of a mild allergic reaction rather than an acute hemolytic reaction.
C. Vomiting: Although nausea and vomiting may occur in various transfusion reactions, it is not specific to an acute hemolytic reaction like low back pain is.
D. Low back pain: Low back pain, often around the kidneys, is a classic sign of an acute hemolytic reaction due to the breakdown of RBCs and the release of hemoglobin into the bloodstream, which can lead to renal damage. This reaction is a medical emergency requiring immediate intervention.
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Correct Answer is B
Explanation
A. Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.
B. Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.
C. Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.
D. Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.
Correct Answer is A
Explanation
A. Activity intolerance related to tissue hypoxia: Pernicious anemia leads to a decrease in the body’s ability to carry oxygen due to a lack of intrinsic factor and subsequent vitamin B12 deficiency, resulting in tissue hypoxia. This can cause fatigue and activity intolerance as the body struggles to meet its oxygen demands.
B. Ineffective airway clearance related to dyspnea: Dyspnea may occur, but ineffective airway clearance is not directly related to pernicious anemia, as this condition primarily affects oxygen transport, not the airway.
C. Risk for infection related to reduction in white blood cells (WBCs): Pernicious anemia primarily affects red blood cells due to vitamin B12 deficiency; it does not typically lead to a reduction in white blood cells.
D. Chronic pain related to bone marrow dysfunction: While bone marrow may be affected in some anemias, chronic pain is not a typical symptom of pernicious anemia, and bone marrow dysfunction is not usually present.