RN Adult
Med Surg
Practice
NCLEX 2023-
2024
What are the findings for acute hemolytic transfusion
reaction and time of onset? - ANSWER-chills, fever,
low-back pain, tachycardia, flushing, hypotension,
chest tightening or pain, tachypnea, nausea, anxiety,
hemoglobinuria, and impending sense of doom.
Immediate or can manifest during subsequent
infusions.
What are the nursing actions for hemolytic
transfusion reaction? - ANSWER-1. Stop transfusion
2. Remove blood from IV access. AVOID infusing
further blood products.
3. Initiate an infusion of 0.9% sodium chloride using
new tubing
4. monitory vital signs and fluid status
5. Send the blood bag and admin set to lab for
testing
Nurse is preparing to administer packed RBCs to a
client who has Hgb of 6 g/dL. Which is the next
action to perform during the first 15 minutes of the
transfusion? - ANSWER-Assess for hemolytic
transfusion reaction
When can a febrile transfusion reaction happen after
a client received blood products? - ANSWERCommonly occurs 2 hr after
Name the findings of febrile transfusion reaction -
ANSWER-Anti-WBC antibodies, chills (increase of
1·C (2·F) or greater from pretransfusion temp,
flushing, hypotension, tachycardia
A nurse is monitoring a client who began receiving a
unit of packed RBCs 10 min ago. Which of the
following findings should the nurse identify as an
indication of a febrile transfusion reaction? -
ANSWER-Heart rate change from 88/min to
120/min.
Client appears flushed
When can an "allergic" transfusion reaction happen?
- ANSWER-During or up to 24 hrs after
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