A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?
Pulmonary congestion
Urticaria
Vomiting
Low back pain
The Correct Answer is D
A. Pulmonary congestion: Pulmonary congestion is associated more with fluid overload or transfusion-associated circulatory overload (TACO), not an acute hemolytic reaction.
B. Urticaria: Urticaria (hives) is more typical of a mild allergic reaction rather than an acute hemolytic reaction.
C. Vomiting: Although nausea and vomiting may occur in various transfusion reactions, it is not specific to an acute hemolytic reaction like low back pain is.
D. Low back pain: Low back pain, often around the kidneys, is a classic sign of an acute hemolytic reaction due to the breakdown of RBCs and the release of hemoglobin into the bloodstream, which can lead to renal damage. This reaction is a medical emergency requiring immediate intervention.
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Correct Answer is B
Explanation
A. Myxedema: Myxedema is associated with hypothyroidism, not multiple myeloma.
B. Pathologic fracture: Advanced multiple myeloma causes bone demineralization and osteolytic lesions, making bones fragile and increasing the risk for pathologic fractures.
C. Retinopathy: Retinopathy is commonly associated with diabetes or hypertension, not with multiple myeloma.
D. Gastrointestinal bleeding: Gastrointestinal bleeding is not a typical complication of multiple myeloma.
Correct Answer is B
Explanation
A. Initiate a 2 L/day fluid restriction: Hydration is crucial in sickle cell crisis to prevent further sickling and reduce blood viscosity. A fluid restriction would worsen the crisis.
B. Assist with administering a blood transfusion: Blood transfusions are commonly given during sickle cell crisis to manage anemia and reduce the concentration of sickled cells, which can improve oxygen delivery and relieve pain.
C. Withhold opioids to avoid dependence: Pain management, including opioids if needed, is essential during a sickle cell crisis. The risk of dependence is secondary to controlling acute pain.
D. Encourage exercise: Rest is recommended during a crisis to reduce oxygen demand and prevent further sickling. Exercise would increase oxygen needs, worsening the crisis.