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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?

A.

Malformed RBCs

B.

A deficiency in vitamin B12

C.

An abundance of immature RBCS

D.

Destruction of RBCs

Answer and Explanation

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 D

Explanation

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.

Correct Answer is B

Explanation

A. WBCs: White blood cell counts may vary in multiple myeloma, but they are not typically increased; in fact, WBC counts can be low due to bone marrow crowding.

B. Calcium: Multiple myeloma often causes hypercalcemia because of increased bone breakdown, leading to the release of calcium into the bloodstream.

C. Absolute neutrophil count: The absolute neutrophil count may actually decrease as a result of bone marrow dysfunction, not increase.

D. Platelets: Platelet counts are often decreased in multiple myeloma due to bone marrow involvement, not increased.

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