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
Explanation
A. While deep breathing can help alleviate pain, it is not the primary cause of pain in sickle cell anemia; this response could minimize the client's experience.
B. Sickle cell anemia causes red blood cells to become rigid and shaped like a sickle, which can obstruct blood flow and lead to vaso-occlusive crises, resulting in pain.
C. Although sickle cell anemia is a genetic disorder, simply stating that the mutated gene causes increased pain is too vague and does not explain the pain mechanism adequately.
D. While anemia can contribute to fatigue and some discomfort, the pain in sickle cell anemia is primarily due to the sickling of red blood cells and subsequent blockage of blood flow, rather than just the lack of hemoglobin.
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.