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 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. 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.