A nurse is assessing a patient with SCD who has just received a blood transfusion.
What should the nurse monitor for during and after the transfusion to ensure the patient's safety?
Signs of transfusion reaction such as fever, chills, rash, or dyspnea.
The patient's response to music therapy.
The patient's fluid intake and output.
The patient's emotional state.
The Correct Answer is A
Choice A rationale:
Monitoring for signs of transfusion reaction is a critical nursing responsibility during and after a blood transfusion.
Transfusion reactions, such as fever, chills, rash, or dyspnea, can occur due to various factors, including compatibility issues or bacterial contamination of the blood product.
Detecting these signs promptly allows for immediate intervention, including stopping the transfusion and providing appropriate treatment.
This ensures the patient's safety and well-being during the transfusion process.
Choice B rationale:
Monitoring the patient's response to music therapy is not a standard nursing assessment during or after a blood transfusion.
While music therapy can have benefits in managing pain and anxiety, it is not directly related to the safety of the transfusion process.
Choice C rationale:
Monitoring the patient's fluid intake and output is essential in many clinical situations, but it is not specifically related to the safety of a blood transfusion.
This parameter is more relevant in assessing the patient's hydration status and renal function.
Choice D rationale:
Monitoring the patient's emotional state is important for overall patient care, but it is not a primary concern during and immediately after a blood transfusion.
The focus during this time should be on detecting any adverse reactions or complications related to the transfusion itself.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Oxygen therapy in the management of SCD is primarily aimed at preventing tissue hypoxia, not providing relief from severe pain.
SCD patients may experience pain due to tissue ischemia caused by the sickling of red blood cells, and oxygen can help prevent this by increasing the oxygen-carrying capacity of the blood.
Choice B rationale:
The primary purpose of oxygen therapy in the management of SCD is to prevent tissue hypoxia.
SCD patients are at risk of vaso-occlusive crises and tissue damage due to reduced oxygen delivery.
Supplemental oxygen helps maintain adequate tissue oxygenation and reduces the risk of complications.
Choice C rationale:
Oxygen therapy is not administered for the purpose of directly administering analgesics.
Analgesics are typically administered separately to manage pain in SCD patients.
Choice D rationale:
Oxygen therapy is not used to induce relaxation.
Its main goal is to improve oxygen saturation and prevent tissue hypoxia in SCD patients.
Correct Answer is C
Explanation
Choice C rationale:
An elevated serum ferritin level in a patient with sickle cell disease (SCD) may signal iron overload.
Iron overload is a potential complication of chronic blood transfusions, which are often required in SCD to treat anemia and prevent complications.
Excessive iron accumulation can lead to organ damage, particularly in the liver, heart, and endocrine glands.
Monitoring and managing iron levels, including serum ferritin, are essential in SCD patients who receive regular transfusions.
Choice A rationale:
An elevated serum ferritin level does not indicate adequate iron stores.
In fact, it suggests the opposite, as it implies an excess of stored iron in the body.
Choice B rationale:
An elevated serum ferritin level is not indicative of iron deficiency anemia.
Iron deficiency anemia is characterized by low serum ferritin levels, as ferritin stores are depleted in this condition.
Choice D rationale:
An elevated serum ferritin level does not reflect normal hemoglobin levels.
Ferritin is a marker of iron storage and does not directly indicate the hemoglobin level, which measures the oxygen-carrying capacity of red blood cells.
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