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 C
Explanation
A. Ineffective airway clearance related to swelling of the lymph nodes: Multiple myeloma primarily affects bone marrow and bones rather than lymph nodes, so this diagnosis is less relevant.
B. Ineffective tissue perfusion related to vascular occlusion: Vascular occlusion is not a common complication of multiple myeloma, although hyperviscosity can occur, especially in advanced stages. However, the primary concern is bone integrity.
C. Risk for injury related to compromised bone integrity: Multiple myeloma weakens bones due to the presence of osteolytic lesions, increasing the risk for fractures. Teaching the family about measures to prevent injury is crucial.
D. Risk for deficit fluid volume related to a bleeding disorder: Multiple myeloma does not usually cause a primary bleeding disorder that would result in fluid volume deficit. Bone fractures and hypercalcemia are more immediate concerns.
Correct Answer is A
Explanation
A. "Aplastic anemia results from decreased bone marrow production of RBCs." Aplastic anemia is characterized by the failure of bone marrow to produce adequate red blood cells (RBCs), white blood cells, and platelets. This results in pancytopenia, which increases the risk of infections, anemia, and bleeding.
B. "Aplastic anemia is directly related to impaired liver function." Aplastic anemia is not related to liver function; it originates from the bone marrow’s inability to produce sufficient blood cells.
C. "Aplastic anemia is associated with the decreased intake of iron." Aplastic anemia is not caused by iron deficiency; it is primarily due to bone marrow failure. Iron deficiency anemia, on the other hand, results from a lack of iron intake or absorption.
D. "Aplastic anemia results in an increased rate of RBC destruction." Increased RBC destruction is characteristic of hemolytic anemia, not aplastic anemia.