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. Red blood cells (RBCs) 5.0 million/mm³ (F 4.2–5.4; M 4.7–6.1): This RBC count is within normal limits and does not indicate a concern related to thrombocytopenia.
B. Hemoglobin 14.5 g/100 mL (F 12–16; M 14–18): Hemoglobin is within normal limits and is not an immediate concern for a patient with ITP, as thrombocytopenia primarily affects platelets, not hemoglobin levels.
C. Platelets 50,000/mm³ (150,000–400,000): A platelet count of 50,000/mm³ is significantly below the normal range and poses a risk for bleeding, which is the primary concern in ITP (immune thrombocytopenic purpura).
D. White blood cells (WBCs) 7,400/mm³ (5,000–10,000): The WBC count is normal and not directly related to thrombocytopenia in ITP, which specifically affects platelets.
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.