A nurse is assessing a client who is receiving a unit of packed red blood cells. Which client statement suggests manifestation of an acute hemolytic reaction?
"I have sharp pain in my lower back."
"I am coughing a lot more now."
"I hear ringing in my ears."
"I feel needles poking in my feet."
The Correct Answer is A
A. Sharp pain in the lower back is a classic symptom of an acute hemolytic reaction, which can occur due to incompatible blood transfusions.
B. Coughing more could indicate a transfusion-related acute lung injury (TRALI) but is not a typical sign of an acute hemolytic reaction.
C. Ringing in the ears can occur with other conditions but is not a common sign of an acute hemolytic reaction.
D. Feeling needles poking in the feet is vague and not specifically associated with acute hemolytic reactions, which are characterized by more severe systemic symptoms.
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Correct Answer is B
Explanation
A. While deep breathing can help alleviate pain, it is not the primary cause of pain in sickle cell anemia; this response could minimize the client's experience.
B. Sickle cell anemia causes red blood cells to become rigid and shaped like a sickle, which can obstruct blood flow and lead to vaso-occlusive crises, resulting in pain.
C. Although sickle cell anemia is a genetic disorder, simply stating that the mutated gene causes increased pain is too vague and does not explain the pain mechanism adequately.
D. While anemia can contribute to fatigue and some discomfort, the pain in sickle cell anemia is primarily due to the sickling of red blood cells and subsequent blockage of blood flow, rather than just the lack of hemoglobin.
Correct Answer is D
Explanation
A. Encouraging frequent ambulation is not appropriate during a vaso-occlusive crisis, as it can exacerbate pain and further compromise blood flow.
B. While monitoring the RBC count is important, it is not the most immediate intervention during a crisis. The focus should be on managing pain and preventing complications.
C. Treating the client in an outpatient setting is inappropriate during a vaso-occlusive crisis, which typically requires inpatient care for effective pain management and hydration.
D. Maintaining IV fluids, administering pain medications, and providing supplemental oxygen are critical interventions that address the acute needs of the client in crisis, aiming to alleviate pain and improve oxygenation.