Fluid & Electrolyte Q 11
Redd is receiving a blood transfusion. When monitoring the patient, the nurse would analyze an elevated body temperature as indicating:
A. A normal physiologic process.
B. Evidence of sepsis.
C. A possible transfusion reaction.
D. An expected response to the transfusion.
Correct Answer: C. A possible transfusion reaction.
An increase in the body temperature indicates a possible transfusion reaction and requires immediate discontinuation of the infusion. Transfusion reactions are defined as adverse events associated with the transfusion of whole blood or one of its components. These may range in severity from minor to life-threatening.
Option A: Reactions can occur during the transfusion (acute transfusion reactions) or days to weeks later (delayed transfusion reactions) and may be immunologic or non-immunologic. A reaction may be difficult to diagnose as it can present with non-specific, often overlapping symptoms.
Option B: The most common signs and symptoms include fever, chills, urticaria (hives), and itching. Some symptoms resolve with little or no treatment. However, respiratory distress, high fever, hypotension (low blood pressure), and red urine (hemoglobinuria) can indicate a more serious reaction.
Option D: Immune-mediated transfusion reactions typically occur due to mismatch or incompatibility of the transfused product and the recipient. They include naturally occurring antibodies in the blood recipient (such as anti-A, anti-B which are typically responsible for acute hemolytic transfusion reactions) as well as antibodies made in response to foreign antigens (alloantibodies).