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 D

Explanation

A. Have the child eat a high-protein diet. There is no specific requirement for a high-protein diet to manage sickle cell disease. Hydration is more critical in crisis prevention.

B. Monitor the child's temperature twice per day. While monitoring for infection is essential, this is not the most important discharge instruction to prevent crises.

C. Restrict outdoor play activity. While strenuous exercise should be avoided, activity restriction is unnecessary as long as the child stays hydrated and avoids extreme conditions.

D. Encourage the child to increase his fluid intake. Increased fluid intake helps prevent sickling by reducing blood viscosity, which is essential in preventing future crises.

A. Heat relaxes the muscles and distracts the patient from the pain. B. Sickle cell crisis pain can be exacerbated with shivering. C. Heat promotes proper formation of red blood cells (RBCs) and prevents sickling. D. Heat increases circulation by preventing vasoconstriction.

Correct Answer is D

Explanation

A. Heat relaxes the muscles and distracts the patient from the pain. While warmth can provide comfort, the main goal is to improve circulation rather than distraction.

B. Sickle cell crisis pain can be exacerbated with shivering. Although shivering may be uncomfortable, it is not the primary reason for using heat during a sickle cell crisis.

C. Heat promotes proper formation of red blood cells (RBCs) and prevents sickling. Heat does not affect RBC formation or prevent sickling. The condition of sickling is due to genetic factors, not temperature.

D. Heat increases circulation by preventing vasoconstriction. In sickle cell crisis, warmth helps prevent vasoconstriction, which can reduce blood flow to areas already compromised by sickled cells. Preventing vasoconstriction may help alleviate pain and improve circulation.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

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