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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View Related questions
Correct Answer is A
Explanation
A. Sharp pain in the lower back is a classic symptom of an acute hemolytic reaction, which can occur due to incompatible blood transfusions.
B. Coughing more could indicate a transfusion-related acute lung injury (TRALI) but is not a typical sign of an acute hemolytic reaction.
C. Ringing in the ears can occur with other conditions but is not a common sign of an acute hemolytic reaction.
D. Feeling needles poking in the feet is vague and not specifically associated with acute hemolytic reactions, which are characterized by more severe systemic symptoms.
Correct Answer is B
Explanation
A. Increasing the consumption of protein-rich foods like baked salmon is beneficial for clients with AIDS, as they often require higher protein intake to support their immune system and overall health.
B. Eating raw fruits and vegetables can pose a risk for clients with compromised immune systems, as these foods may harbor pathogens that can lead to infections. This statement indicates a need for further education regarding safe food handling and preparation.
C. Washing plates and utensils with soap and hot water is a proper practice to maintain hygiene and prevent infections, especially for clients with weakened immune systems.
D. Asking a partner to clean the cat's litter box is a good precaution since cat litter can be a source of toxoplasmosis, which can be harmful to immunocompromised individuals.