Question

A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

Answer 1

Correct Answers:

Ensuring the blood is compatible with the client's blood type

Rationale :

🩸Acute hemolytic reactions occur when incompatible blood is transfused, causing the immune system to destroy donor red blood cells.

🧬This reaction can result in serious complications such as renal failure, hypotension, or death.

🧾Verifying the correct blood type with another nurse and using the correct unit is the most effective prevention strategy.

🚫Rapid infusion, premedication, or warming do not prevent this reaction if the blood is incompatible.

📌core message

Always verify blood compatibility to prevent acute hemolytic transfusion reactions.

Answer 2

Correct Answers:

Candidiasis

Rationale :

🦠Clients with AIDS are immunocompromised and prone to opportunistic infections like oral candidiasis, which appears as white lesions on the tongue or inside the mouth.

🧫This fungal infection is common when CD4 counts fall below 200, making it a clinical indicator of progression to AIDS.

🦷Xerostomia is dry mouth, halitosis is bad breath, and gingivitis is gum inflammation—none match the typical white lesions.

🧪Diagnosis is usually confirmed by clinical exam or scraping of the lesions.

📌core message

White tongue lesions in clients with AIDS are usually caused by oral candidiasis, an opportunistic infection.

Answer 3

Correct Answers:

Vitamin B injections

Rationale :

💉Pernicious anemia is caused by vitamin B12 deficiency due to a lack of intrinsic factor required for absorption in the gut.

🧬Oral supplements are often ineffective, so parenteral vitamin B12 injections are required to correct the deficiency.

🩸This condition does not benefit from iron supplements or transfusions unless another cause of anemia is present.

💊Hydroxyurea is used in conditions like sickle cell disease, not B12 deficiency.

📌core message

Pernicious anemia requires vitamin B12 injections due to impaired intestinal absorption.

Answer 4

Correct Answers:

Generalized urticaria.

Rationale :

🌡️An allergic transfusion reaction presents with itching, hives (urticaria), and sometimes mild fever or flushing.

🩹This type of reaction involves immune hypersensitivity to plasma proteins in the donor blood.

🚫Flank pain suggests a hemolytic reaction, while distended neck veins indicate fluid overload, and elevated BP is not specific to allergic reactions.

🛑Mild allergic reactions may be treated with antihistamines and do not always require stopping the transfusion unless symptoms worsen.

📌core message

Allergic transfusion reactions commonly present with generalized hives or urticaria.

Answer 5

Correct Answers:

117

Rationale :

🧮To calculate: 350 mL ÷ 3 hr = 116.6 mL/hr, which rounds to 117 mL/hr.

💉This ensures the blood is transfused within the safe 4-hour window to prevent bacterial growth.

📏Precision in infusion rates is critical to avoid volume overload or delayed administration.

🩺Use an IV pump for accuracy during blood transfusions.

📌core message

Set the infusion rate to 117 mL/hr to transfuse 350 mL over 3 hours safely.

Answer 6

Correct Answers:

Dehydration

Rationale :

💧Dehydration reduces plasma volume and increases blood viscosity, promoting the sickling of red blood cells in sickle cell anemia.

🌬️This leads to vaso-occlusion, which is the main cause of painful crises.

🚫NSAIDs and vaccines are not triggers; in fact, vaccines are preventive in sickle cell patients.

🧪Overhydration is not a known risk factor and may even help dilute blood viscosity.

📌core message

Dehydration is a major trigger for sickle cell crisis due to increased blood viscosity and occlusion.

Answer 7

Correct Answers:

Flu-like symptoms and night sweats

Rationale :

🤒Acute HIV infection often begins with non-specific symptoms, including fever, fatigue, sore throat, night sweats, and muscle aches.

🧬These symptoms are easily mistaken for the flu and occur within 2–4 weeks of exposure.

🦠Kaposi’s sarcoma and pneumocystis infections occur in later stages of AIDS when CD4 counts are much lower.

📋Early recognition supports timely testing and intervention.

📌core message

Initial HIV symptoms mimic the flu and include night sweats and fatigue during the acute phase.

Answer 8

Correct Answers:

"Your red blood cells are not the correct shape, and that causes blood flow to become blocked!"

Rationale :

🩸Sickle-shaped red cells become rigid and clump together, causing blockages in small vessels.

💥This results in tissue ischemia and severe pain, known as a vaso-occlusive crisis.

💬Explaining this pathophysiology empowers the client to understand the cause of pain.

🚫Statements blaming the client or providing incorrect explanations undermine therapeutic communication.

📌core message

In sickle cell anemia, misshapen red blood cells block circulation, leading to severe pain.

Answer 9

Correct Answers:

Viral load count

Rationale :

🧪Viral load testing measures the amount of HIV RNA in the blood and reflects the effectiveness of antiretroviral therapy (ART).

📉A decreasing viral load indicates treatment success, while rising levels may suggest drug resistance.

🧬Western blot and EIA are for diagnosis, not treatment monitoring.

🩸Platelet count is not directly related to HIV management effectiveness.

📌core message

Viral load is the best indicator of HIV treatment effectiveness, showing changes in viral replication.

Answer 10

Correct Answers:

CD4-T-cell count 180 cells/mm3 (Range: 500 to 1500 cells/mm3)

Rationale :

🧬A CD4 count below 200 cells/mm³ indicates severe immunosuppression and defines progression to AIDS.

⚠️This value requires provider notification for treatment review and infection prevention.

🔬WBC and platelet counts may still be normal, and a positive Western blot is diagnostic, not an urgent finding post-diagnosis.

🩺This lab result often prompts prophylaxis for opportunistic infections.

📌core message

A CD4 count under 200 means advanced HIV, requiring prompt provider notification and preventive interventions.

1 :
A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

2 :
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). The nurse notes white lesions on the client's tongue. What opportunistic infection is this client experiencing?

3 :
A nurse is planning care for a client with pemicious anemia. Which intervention should the nurse plan to implement?

4 :
A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

5 :
A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A nurse is providing education to a client diagnosed with sickle cell anemia. Which of the following can be anticipated will be a trigger for a sickle cell crisis?

7 :
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which manifestation(s) should the nurse include?

8 :
A nurse is caring for a client with sickle cell anemia. The client asks, "Why am I in so much pain?" What is an appropriate response from the nurse to make to this client?

9 :
A nurse is caring for a client with HIV. Which laboratory test would be used to assess the effectiveness of therapy?

10 :
A nurse is caring for a client who has human immunodeficiency virus (HIV). Which laboratory value should the nurse alert the provider of?

1 : A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

2 : A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). The nurse notes white lesions on the client's tongue. What opportunistic infection is this client experiencing?

3 : A nurse is planning care for a client with pemicious anemia. Which intervention should the nurse plan to implement?

4 : A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

5 : A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

6 : A nurse is providing education to a client diagnosed with sickle cell anemia. Which of the following can be anticipated will be a trigger for a sickle cell crisis?

7 : A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which manifestation(s) should the nurse include?

8 : A nurse is caring for a client with sickle cell anemia. The client asks, "Why am I in so much pain?" What is an appropriate response from the nurse to make to this client?

9 : A nurse is caring for a client with HIV. Which laboratory test would be used to assess the effectiveness of therapy?

10 : A nurse is caring for a client who has human immunodeficiency virus (HIV). Which laboratory value should the nurse alert the provider of?

1 :
A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

2 :
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). The nurse notes white lesions on the client's tongue. What opportunistic infection is this client experiencing?

3 :
A nurse is planning care for a client with pemicious anemia. Which intervention should the nurse plan to implement?

4 :
A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

5 :
A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A nurse is providing education to a client diagnosed with sickle cell anemia. Which of the following can be anticipated will be a trigger for a sickle cell crisis?

7 :
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which manifestation(s) should the nurse include?

8 :
A nurse is caring for a client with sickle cell anemia. The client asks, "Why am I in so much pain?" What is an appropriate response from the nurse to make to this client?

9 :
A nurse is caring for a client with HIV. Which laboratory test would be used to assess the effectiveness of therapy?

10 :
A nurse is caring for a client who has human immunodeficiency virus (HIV). Which laboratory value should the nurse alert the provider of?