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

Answer and Explanation

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 B

Explanation

A. Myxedema: Myxedema is associated with hypothyroidism, not multiple myeloma.

B. Pathologic fracture: Advanced multiple myeloma causes bone demineralization and osteolytic lesions, making bones fragile and increasing the risk for pathologic fractures.

C. Retinopathy: Retinopathy is commonly associated with diabetes or hypertension, not with multiple myeloma.

D. Gastrointestinal bleeding: Gastrointestinal bleeding is not a typical complication of multiple myeloma.

A. Activity intolerance related to tissue hypoxia B. Ineffective airway clearance related to dyspnea. C. Risk for infection related to reduction in white blood cells (WBCs) D. Chronic pain related to bone marrow dysfunction

Correct Answer is A

Explanation

A. Activity intolerance related to tissue hypoxia: Pernicious anemia leads to a decrease in the body’s ability to carry oxygen due to a lack of intrinsic factor and subsequent vitamin B12 deficiency, resulting in tissue hypoxia. This can cause fatigue and activity intolerance as the body struggles to meet its oxygen demands.

B. Ineffective airway clearance related to dyspnea: Dyspnea may occur, but ineffective airway clearance is not directly related to pernicious anemia, as this condition primarily affects oxygen transport, not the airway.

C. Risk for infection related to reduction in white blood cells (WBCs): Pernicious anemia primarily affects red blood cells due to vitamin B12 deficiency; it does not typically lead to a reduction in white blood cells.

D. Chronic pain related to bone marrow dysfunction: While bone marrow may be affected in some anemias, chronic pain is not a typical symptom of pernicious anemia, and bone marrow dysfunction is not usually present.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in planning care for a client who has advanced multiple myeloma. When planning care the nurse should recognize that the client is at risk for which of the following complications?

Correct Answer is B

Explanation

The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?

Correct Answer is A

Explanation

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