Difficulty: Medium
Average Score: 80%
Simulated
The nurse cares for a client receiving mechanical ventilation who is prescribed one unit of packed red blood cells to be transfused. Which finding would alert the nurse of a transfusion-related reaction?
Correct answer
D
Rationale
Hemoglobinuria (blood in the urine) is a hallmark of a hemolytic transfusion reaction, indicating red blood cell destruction. Low-pressure alarms relate to ventilator issues, increased glucose is unrelated, and diminished lung sounds may suggest other issues but not specifically transfusion reactions.