A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?
2 hr
8 hr
6 hr
4 hr
The Correct Answer is D
A. 2 hr: While some patients may tolerate faster infusion rates, the maximum safe time is 4 hours, and there is no requirement to complete it in 2 hours.
B. 8 hr: Blood cannot be left out for 8 hours due to the increased risk of bacterial growth and contamination.
C. 6 hr: Infusing blood over 6 hours exceeds the safe time limit and poses a risk of bacterial contamination.
D. 4 hr: To reduce the risk of bacterial contamination, a unit of packed RBCs must be transfused within 4 hours of starting the infusion. This time frame ensures that the blood remains safe for the patient while minimizing exposure to room temperature.
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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 D
Explanation
A. RBC's: Red blood cells (RBCs) are not indicative of Hodgkin’s lymphoma; they are involved in oxygen transport throughout the body and are not a specific marker for any lymphoma.
B. Bence-Jones Cells: Bence-Jones proteins are light chain proteins found in the urine of patients with multiple myeloma, not Hodgkin’s lymphoma.
C. Stem Cells: Stem cells are progenitor cells that can develop into various blood cell types but are not characteristic of Hodgkin’s lymphoma specifically. Reed-Sternberg cells, not stem cells, are the hallmark of this disease.
D. Reed-Sternberg Cell: Reed-Sternberg cells are large, abnormal B cells that are characteristic of Hodgkin’s lymphoma. Their presence in lymph node tissue is a key diagnostic feature of the disease.