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 A
Explanation
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C. The Enzyme immunoassay (EIA) test is used for initial HIV screening but does not measure viral load or therapy effectiveness.
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Correct Answer is B
Explanation
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B. Fatigue is a common symptom in clients with anemia, particularly when hemoglobin levels are low, as there is reduced oxygen delivery to tissues, leading to feelings of weakness and tiredness.
C. Hypertension is unlikely to be present in a client with significant blood loss; instead, hypotension may be more expected due to reduced blood volume.
D. Bradycardia is not typically associated with anemia; in fact, tachycardia (increased heart rate) is more common as the body tries to compensate for reduced oxygen-carrying capacity.