A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction?

Choice A reason: This is incorrect because aspirin is not a suitable medication for preventing venous thromboembolism (VTE) in a client who is postoperative following hip arthroplasty. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that has antiplatelet and analgesic effects, but it is not as effective as anticoagulants for VTE prophylaxis.

Choice B reason: This is incorrect because alteplase is not a medication for preventing VTE, but for treating it. Alteplase is a thrombolytic agent that dissolves existing blood clots by activating plasminogen. It is used for acute ischemic stroke, myocardial infarction, and massive pulmonary embolism, but it has a high risk of bleeding and is contraindicated in clients who have had recent surgery.

Choice C reason: This is incorrect because clopidogrel is not a medication for preventing VTE, but for preventing arterial thrombosis. Clopidogrel is an antiplatelet agent that inhibits the adenosine diphosphate (ADP) receptor on platelets, preventing their aggregation. It is used for clients who have had acute coronary syndrome, percutaneous coronary intervention, or ischemic stroke, but it is not effective for VTE prophylaxis.

Choice D reason: This is correct because enoxaparin is a medication for preventing VTE in a client who is postoperative following hip arthroplasty. Enoxaparin is a low molecular weight heparin (LMWH) that inhibits factor Xa and thrombin, preventing the formation of fibrin. It is administered subcutaneously once or twice daily and does not require routine laboratory monitoring. It has a lower risk of bleeding and heparin-induced thrombocytopenia (HIT) than unfractionated heparin.

Choice A reason: Client report of a headache is not the nurse's priority to report to the provider. A headache is a common and mild side effect of vancomycin, which is an antibiotic used to treat serious infections. A headache may be caused by dehydration, stress, or other factors, and can be relieved by drinking fluids, resting, or taking analgesics.

Choice B reason: Audible inspiratory stridor is the nurse's priority to report to the provider. Stridor is a high-pitched, wheezing sound that occurs when breathing in, and indicates a narrowing or obstruction of the airway. Stridor may be a sign of a severe allergic reaction, or anaphylaxis, to vancomycin, which can be life-threatening. Anaphylaxis can also cause swelling of the face, lips, tongue, or throat, difficulty breathing, low blood pressure, and shock. The nurse should stop the infusion, administer epinephrine, and monitor the client's vital signs.

Choice C reason: Client report of tinnitus is not the nurse's priority to report to the provider. Tinnitus is a ringing or buzzing sound in the ears, and may be a rare and serious side effect of vancomycin. Tinnitus may indicate damage to the inner ear, or ototoxicity, which can lead to hearing loss. The nurse should check the client's hearing and report any changes to the provider. The provider may adjust the dose or frequency of vancomycin, or switch to another antibiotic.

Choice D reason: Localized redness at the catheter insertion site is not the nurse's priority to report to the provider. Redness at the catheter insertion site may indicate irritation, inflammation, or infection of the skin or vein, and may be caused by the needle, the catheter, or the medication. The nurse should inspect the site, clean it with antiseptic, and apply a sterile dressing. The nurse should also monitor the site for signs of phlebitis, such as pain, swelling, warmth, or pus. The nurse may need to change the catheter or the infusion site if the redness persists or worsens.