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 D
Explanation
A. Encouraging frequent ambulation is not appropriate during a vaso-occlusive crisis, as it can exacerbate pain and further compromise blood flow.
B. While monitoring the RBC count is important, it is not the most immediate intervention during a crisis. The focus should be on managing pain and preventing complications.
C. Treating the client in an outpatient setting is inappropriate during a vaso-occlusive crisis, which typically requires inpatient care for effective pain management and hydration.
D. Maintaining IV fluids, administering pain medications, and providing supplemental oxygen are critical interventions that address the acute needs of the client in crisis, aiming to alleviate pain and improve oxygenation.
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.