The nurse is caring for a patient receiving treatment for a hemolytic reaction from a mismatched blood transfusion. The nurse understands that this the incompatible blood is causing what?
Malformed RBCs
A deficiency in vitamin B12
An abundance of immature RBCS
Destruction of RBCs
The Correct Answer is D
A. Malformed RBCs: Malformed RBCs are not caused by a transfusion reaction; they are generally a result of bone marrow abnormalities or genetic conditions.
B. A deficiency in vitamin B12: Vitamin B12 deficiency causes megaloblastic anemia, not hemolysis. It is unrelated to transfusion reactions.
C. An abundance of immature RBCs: Immature RBCs, or reticulocytes, can increase as a compensatory response to anemia but are not a direct result of a transfusion reaction. The primary issue is RBC destruction.
D. Destruction of RBCs: A hemolytic reaction occurs when the immune system attacks incompatible red blood cells, leading to their destruction.
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Correct Answer is B
Explanation
A. "My son will have to grow a beard." Growing a beard is irrelevant to managing hemophilia and preventing bleeding.
B. "My son will have to avoid contact sports." Avoiding contact sports is essential for children with hemophilia to reduce the risk of trauma and bleeding episodes due to their clotting factor deficiency.
C. "My son will have to avoid fresh foods such as fruit in his diet." Fresh foods like fruits do not pose a bleeding risk for hemophilia; dietary restrictions are generally unnecessary in managing this condition.
D. "My son will always have to live near a major hospital."While proximity to a healthcare facility can be helpful in emergencies, this is not a requirement for managing hemophilia, nor does it directly prevent bleeding episodes.
Correct Answer is B
Explanation
A. Have the patient take a number and stay in the waiting area. Delaying care could lead to worsening of a potentially life-threatening bleeding episode. Hemophilia patients should be assessed promptly.
B. Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis. Hemophilia patients are at risk of internal bleeding, which may not always be visible externally. Rapid assessment is essential to prevent complications from internal bleeding.
C. Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room. X-rays may not immediately detect bleeding in soft tissues. The physician should evaluate the patient first.
D. Palpate the suspected area of bleeding for tenderness and edema. Palpating could worsen bleeding or cause pain, and the nurse should focus on ensuring the patient is seen promptly by the physician.