ATI Pretest & Posttest - Blood Administration

A nurse started a transfusion of packed RBC's for a client 1 hour ago. The client has suddenly developed shaking chills, muscle stiffness, and a temperature of 38.6 C (101.5 F). The client appears flushed and reports a headache and "nervousness." The nurse should identify that the client has most likely developed which type of transfusion reaction? A. Septic B. Acute hemolytic C. Allergic D. Febrile nonhemolytic - Answer$D. Febrile nonhemolytic This is the most common type of transfusion reaction. The characteristic fever usually develops within 2 hr after the transfusion is started. Other classic symptoms include chills, headache, flushing, anxiety and muscle pain. This type of reaction is usually a result of sensitization to the plasma, platelets, or WBC. Although this type of reaction is not life threatening, it can be frightening and uncomfortable for the client. A platelet transfusion is indicated for a patient who A. has a systemic function B. has thrombocytopenia C. is in hypovolemic shock D. has hemolytic anemia - Answer$B. has thrombocytopenia A client who has thrombocytopenia has a low platelet count. When platelet counts drop below 20,000/mm3, a transfusion of platelets is generally indicated for the client A nurse is providing education to a client who has a prescription for a blood transfusion. Which of the following statements should the nurse include in the teaching? A. " I will check your vital signs every 15 minutes throughout the blood transfusion." B. " I might have a nursing assistant check on you periodically during the transfusion C. If you have no adverse effects in the first 15 to 30 minutes, you will not have any adverse effects later." D. " You must immediately report any symptoms like chills, nausea, itching." - Answer$D. " You must immediately report any symptoms like chills, nausea, itching." Although the nurse can identify objective signs of a transfusion reaction (changes in vital signs, flushing, cyanosis, coughing, and to some extent, dyspnea), the nurse might not be able to tell if the client is experiencing subjective symptoms (chills, nausea, chest pain, headache, backache, muscle pain). Subjective signs are important clues, and the nurse must be aware of them.