A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Distended jugular veins.
Generalized urticaria.
Bilateral flank pain.
Blood pressure 184/92 mm Hg.
The Correct Answer is B
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.
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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.
Correct Answer is C
Explanation
A. Decreasing intake of foods high in fiber is not necessary; in fact, fiber can help prevent constipation, a common side effect of iron supplements.
B. Vitamin C actually enhances the absorption of iron; thus, avoiding it is incorrect. Clients should be encouraged to consume vitamin C alongside their iron supplements to improve absorption.
C. Stools becoming darker in color is a common and expected side effect of ferrous sulfate due to the presence of unabsorbed iron. It is important for clients to know this to avoid unnecessary alarm.
D. Taking the medication on a full stomach may decrease absorption; it is generally recommended to take iron supplements on an empty stomach for optimal absorption unless gastrointestinal upset occurs.