Question

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

a) Fever and chills
b) Hypertension
c) Increased urine output
d) Decreased respiratory rate

Answer 1

A nurse is administering packed RBCs to a client. The assessment finding that indicates a hemolytic transfusion reaction is fever and chills.

Step-by-step explanation:

A hemolytic transfusion reaction occurs when a patient receives incompatible blood during a transfusion. The destruction of red blood cells in this reaction can lead to several assessment findings.

1. Fever and chills: This is a common symptom of a hemolytic reaction and occurs as a result of the inflammatory response triggered by the destruction of red blood cells.
2. Hypertension: Hypertension is not typically associated with a hemolytic transfusion reaction. Instead, hypotension or low blood pressure is a common finding due to the release of inflammatory mediators.
3. Increased urine output: Increased urine output is not directly related to a hemolytic transfusion reaction. However, hemoglobinuria, the presence of hemoglobin in the urine, can occur as a result of red blood cell destruction.
4. Decreased respiratory rate: This is not a typical finding in a hemolytic transfusion reaction. Instead, the patient may experience dyspnea or difficulty breathing due to the inflammatory response.

Based on these assessment findings, the correct answer is a) Fever and chills, as they indicate an inflammatory response in a hemolytic transfusion reaction.