The nurse is caring for a patient receiving treatment for a hemolytic reaction from a mismatched blood transfusion. The nurse understands that this the incompatible blood is causing what?

Malformed RBCs

A deficiency in vitamin B12

An abundance of immature RBCS

Destruction of RBCs

Answer and Explanation

The Correct Answer is D

A. Malformed RBCs: Malformed RBCs are not caused by a transfusion reaction; they are generally a result of bone marrow abnormalities or genetic conditions.

B. A deficiency in vitamin B12: Vitamin B12 deficiency causes megaloblastic anemia, not hemolysis. It is unrelated to transfusion reactions.

C. An abundance of immature RBCs: Immature RBCs, or reticulocytes, can increase as a compensatory response to anemia but are not a direct result of a transfusion reaction. The primary issue is RBC destruction.

D. Destruction of RBCs: A hemolytic reaction occurs when the immune system attacks incompatible red blood cells, leading to their destruction.

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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. Explain the procedure to the patient’s family B. Observe the patient for bleeding C. Drape the biopsy site D. Administer an analgesic to the patient

Correct Answer is D

Explanation

A. Explain the procedure to the patient’s family: While helpful, this is not as crucial as ensuring patient comfort and pain management during the procedure itself.

B. Observe the patient for bleeding: Observing for bleeding is important post-procedure rather than beforehand.

C. Drape the biopsy site: Draping is part of the procedure setup, but pain management is more critical for patient preparation.

D. Administer an analgesic to the patient: Administering an analgesic is essential to manage pain and discomfort during a bone marrow biopsy. This ensures the patient is as comfortable as possible.

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The nurse is caring for a patient receiving treatment for a hemolytic reaction from a mismatched blood transfusion. The nurse understands that this the incompatible blood is causing what?

Nursing Test Bank

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

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?

Correct Answer is D

Explanation

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