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 D
Explanation
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.
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.