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A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

A.

Distended jugular veins.

B.

Generalized urticaria.

C.

Bilateral flank pain.

D.

Blood pressure 184/92 mm Hg.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

A. Over-hydration is not a trigger for a sickle cell crisis; in fact, adequate hydration helps prevent sickling of the cells.

B. Dehydration is a significant trigger for sickle cell crises, as it can lead to increased blood viscosity and sickling of red blood cells.

C. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used to manage pain associated with sickle cell crises, but they do not trigger a crisis.

D. Vaccinations are important for preventing infections in individuals with sickle cell anemia but are not associated with triggering a sickle cell crisis.

Correct Answer is A

Explanation

A. Ensuring the blood is compatible with the client's blood type is critical in preventing an acute hemolytic reaction, as incompatible blood transfusions can cause serious, potentially life-threatening reactions.

B. Administering the transfusion rapidly can increase the risk of complications and does not prevent hemolytic reactions; transfusions should be given at a safe rate based on the client's condition.

C. Using a blood warmer is not a standard intervention to prevent hemolytic reactions; it's typically used in specific cases such as massive transfusions or hypothermia, but it does not address compatibility.

D. Administering prophylactic antihistamines is not a recommended practice to prevent hemolytic reactions; it is more relevant for preventing allergic reactions associated with transfusions.

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