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. Milk and cheese are low in iron content and are not recommended for increasing iron levels in clients with iron-deficiency anemia.
B. Whole grain breads may contain some iron but are not as high in iron as other food sources.
C. Fresh fruits do not provide significant amounts of iron and are not a good source for addressing iron deficiency.
D. Red meat and organ meat are excellent sources of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant sources, making them the best choice for increasing iron intake in clients with iron-deficiency anemia.
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.