A unit of packed red blood cells was ordered for a patient. Twenty minutes after the blood began infusing, the patient developed dyspnea, chest pain, bloody urine, and a decrease in blood pressure
The nurse would characterize this as which type of transfusion reaction? 1. Allergic
2. Febrile nonhemolytic
3. Delayed hemolytic
4. Acute hemolytic
4
Rationale 1: Allergic reactions are manifested by itching, hives, flushing, and chills.
Rationale 2: Febrile nonhemolytic reactions are manifested by increased pulse rate, temperature increase of 1°C, chills, headache, nausea and vomiting, anxiety, flushing, back pain, and muscle aches.
Rationale 3: Delayed hemolytic reactions are manifested by fever, anemia, increased bilirubin level, decreased or absent haptoglobin, and jaundice.
Rationale 4: Bloody urine and decreased urine output, petechiae, jaundice, decreased blood pressure, chest tightness, low back pain, nausea, anxiety, dyspnea, hypotension, bronchospasm, hemoglobinemia, acute renal failure, shock, cardiac arrest, and death are symptoms that typically occur within the first 15 minutes of the transfusion with an acute hemolytic reaction.
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