A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?

Jaw Pain

Urticaria

Distended neck veins

Hypotension

Answer and Explanation

The Correct Answer is D

A. Jaw Pain: Jaw pain is not typically associated with a hemolytic transfusion reaction. It may be more relevant in cardiac issues or in rare cases of referred pain, but it is not an indicator of transfusion reaction.

B. Urticaria: Urticaria (hives) is associated with allergic reactions, not specifically with hemolytic reactions. Acute hemolytic reactions are characterized more by systemic symptoms like hypotension and fever.

C. Distended neck veins: Distended neck veins suggest fluid overload or cardiac issues but are not characteristic of an acute hemolytic reaction.

D. Hypotension: Hypotension is a common sign of an acute hemolytic transfusion reaction. This occurs when the immune system attacks transfused red blood cells, leading to hemolysis, which can cause shock and a drop-in blood pressure.

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Correct Answer is D

Explanation

A. Have the child eat a high-protein diet. There is no specific requirement for a high-protein diet to manage sickle cell disease. Hydration is more critical in crisis prevention.

B. Monitor the child's temperature twice per day. While monitoring for infection is essential, this is not the most important discharge instruction to prevent crises.

C. Restrict outdoor play activity. While strenuous exercise should be avoided, activity restriction is unnecessary as long as the child stays hydrated and avoids extreme conditions.

D. Encourage the child to increase his fluid intake. Increased fluid intake helps prevent sickling by reducing blood viscosity, which is essential in preventing future crises.

A. WBCS B. Calcium C. Absolute neutrophil count D. Platelets

Correct Answer is B

Explanation

A. WBCs: White blood cell counts may vary in multiple myeloma, but they are not typically increased; in fact, WBC counts can be low due to bone marrow crowding.

B. Calcium: Multiple myeloma often causes hypercalcemia because of increased bone breakdown, leading to the release of calcium into the bloodstream.

C. Absolute neutrophil count: The absolute neutrophil count may actually decrease as a result of bone marrow dysfunction, not increase.

D. Platelets: Platelet counts are often decreased in multiple myeloma due to bone marrow involvement, not increased.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the discharge of a child who has sickle cell anemia and is recovering from an acute sickle cell crisis. Which of the following instructions should the nurse reinforce with the child's parents?

Correct Answer is D

Explanation

A nurse is reviewing laboratory findings for a client admitted with multiple myeloma. The nurse should expect to see an increase in which of the following laboratory tests?

Correct Answer is B

Explanation

The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which priority action by the nurse is most appropriate at this time?

A nurse is reinforcing teaching with a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should tell the client that, in addition to the iliac crest, a common site for this procedure is which of the following?

A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?

A nurse is assisting in planning care for a client who has advanced multiple myeloma. When planning care the nurse should recognize that the client is at risk for which of the following complications?

The nurse is caring for a patient with a clotting disorder. Which should the nurse plan to administer?

A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?

The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the following interventions is most important for the nurse to carry out before the procedure?