A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?

Jaw Pain

Urticaria

Distended neck veins

Hypotension

Answer and Explanation

The Correct Answer is D

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.

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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.

Correct Answer is ["1610"]

Explanation

Solution:

Convert ounces to milliliters (1 oz = 30 mL):
- Coffee: 8 oz × 30 mL = 240 mL
- Juice: 3 oz × 30 mL = 90 mL
- Soda: 12 oz × 30 mL = 360 mL
Calculate water intake:
- Initial pitcher: 800 mL
- Remaining: 200 mL
- Water intake = 800 mL - 200 mL = 600 mL
Calculate IV fluids intake:
- IV rate: 40 mL/hr
- Time: 8 hours
- IV fluids = 40 mL/hr × 8 hrs = 320 mL
Total intake:
- 240 mL (coffee) + 90 mL (juice) + 360 mL (soda) + 600 mL (water) + 320 mL (IV) = 1610 mL

Answer: 1610 mL

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Naxlex Comprehensive Predictor Exams

What types of cells are present in Hodgkin's lymphoma?

Correct Answer is D

Explanation

Correct Answer is ["1610"]

Explanation

A nurse is collecting data from a client who has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings?

The nurse is caring for a patient with a clotting disorder. Which should the nurse plan to administer?

The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?

The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?

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