Difficulty: Medium
Average Score: 87%
Simulated
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of 'tightness' in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?
Correct answer
B
Rationale
The correct answer is B: Acute hemolytic transfusion reaction. This type of reaction occurs when there is a mismatch between the donor and recipient blood types, leading to the rapid destruction of the infused red blood cells. The symptoms presented by the client, such as chills, headache, low-back pain, and chest tightness, are indicative of a severe immune response causing the release of cytokines and other inflammatory mediators. It is crucial for the nurse to recognize these signs promptly as this reaction can be life-threatening if not addressed immediately.
Other choices are incorrect because:
A: Allergic reactions typically present with symptoms like itching, hives, and mild respiratory distress, not the severe symptoms described in the scenario.
C: Bacterial reactions occur due to contaminated blood products and usually manifest with fever, chills, and hypotension, rather than the specific symptoms mentioned.
D: Febrile nonhemolytic reactions are characterized by fever and chills, without the additional symptoms
Other choices are incorrect because:
A: Allergic reactions typically present with symptoms like itching, hives, and mild respiratory distress, not the severe symptoms described in the scenario.
C: Bacterial reactions occur due to contaminated blood products and usually manifest with fever, chills, and hypotension, rather than the specific symptoms mentioned.
D: Febrile nonhemolytic reactions are characterized by fever and chills, without the additional symptoms