A nurse is assessing a client who is having a blood transfusion. The blood transfusion was ordered after the laboratory test revealed a hemoglobin level of nine g/dL While transfusing the first unit of blood, the client complained of flank pain. The client's blood pressure is dropping and the heart rate is racing. These symptoms indicate:
A)Delayed hemolytic reaction
B)Anaphylactic reaction
C)Febrile reaction
D)Acute hemolytic reaction

Question

Quizplus · Accepted Answer

The presenting symptoms are most likely associated with an acute hemolytic reaction that usually results from ABO incompatibility. Delayed hemolysis occurs weeks or months after the blood transfusion. In the case of acute hemolysis, the transfusion should be terminated immediately and the unit rechecked for compatibility. The doctor may order the client catheterized in order to check for hematuria.

A Nurse Is Assessing a Client Who Is Having a Blood