A nurse is collecting data from a client who has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings?
Intense abdominal pain
Respiratory depression
Dyspnea on exertion
Bradycardia
The Correct Answer is C
A. Intense abdominal pain: While abdominal pain may occur in some conditions related to anemia, it is not a typical finding in anemia due to blood loss.
B. Respiratory depression: Respiratory depression is not commonly associated with anemia and would more likely indicate issues with central nervous system depression or drug side effects.
C. Dyspnea on exertion: Dyspnea on exertion is common in clients with anemia because of the decreased oxygen-carrying capacity of the blood, leading to tissue hypoxia. Anemia results in decreased hemoglobin levels, reducing the body’s ability to deliver adequate oxygen, particularly during physical activity.
D. Bradycardia: Anemia typically causes tachycardia (increased heart rate) rather than bradycardia, as the body compensates for low oxygen levels by increasing cardiac output.
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Correct Answer is D
Explanation
A. Jaw Pain: Jaw pain is not typically associated with a hemolytic transfusion reaction. It may be more relevant in cardiac issues or in rare cases of referred pain, but it is not an indicator of transfusion reaction.
B. Urticaria: Urticaria (hives) is associated with allergic reactions, not specifically with hemolytic reactions. Acute hemolytic reactions are characterized more by systemic symptoms like hypotension and fever.
C. Distended neck veins: Distended neck veins suggest fluid overload or cardiac issues but are not characteristic of an acute hemolytic reaction.
D. Hypotension: Hypotension is a common sign of an acute hemolytic transfusion reaction. This occurs when the immune system attacks transfused red blood cells, leading to hemolysis, which can cause shock and a drop-in blood pressure.
Correct Answer is B
Explanation
A. Progressive increase in platelet production: In DIC, platelets are rapidly consumed, not increased, due to widespread clotting in the blood vessels.
B. Excessive thrombosis and bleeding: DIC is a complex condition where there is widespread activation of the clotting cascade, leading to excessive clotting and subsequent depletion of platelets and clotting factors, resulting in both thrombosis and bleeding.
C. Immediate sodium and fluid retention: Sodium and fluid retention are not specific findings in DIC; they may occur in cases of renal or heart failure but are unrelated to the clotting issues in DIC.
D. Increased clotting factors: In DIC, clotting factors are depleted as they are used up in widespread clotting, leading to bleeding when factors are exhausted.