The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the following interventions is most important for the nurse to carry out before the procedure?
Explain the procedure to the patient’s family
Observe the patient for bleeding
Drape the biopsy site
Administer an analgesic to the patient
The Correct Answer is D
A. Explain the procedure to the patient’s family: While helpful, this is not as crucial as ensuring patient comfort and pain management during the procedure itself.
B. Observe the patient for bleeding: Observing for bleeding is important post-procedure rather than beforehand.
C. Drape the biopsy site: Draping is part of the procedure setup, but pain management is more critical for patient preparation.
D. Administer an analgesic to the patient: Administering an analgesic is essential to manage pain and discomfort during a bone marrow biopsy. This ensures the patient is as comfortable as possible.
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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.
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.