A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?
Infuse 0.9% sodium chloride IV.
Administer an antipyretic.
Decrease the infusion rate to 75 mL/hr.
Place the client in a left lateral position.
The Correct Answer is A
A.
A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop
the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.
B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.
C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.
D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["92"]
Explanation
- Pulse pressure is the difference between systolic and diastolic blood pressure.
- The client's pulse pressure is 132 - 40 = 92 mm Hg.
Correct Answer is A
Explanation
A.
A. Monitor for abdominal ascites - Ascites is a common complication of cirrhosis due to portal hypertension and decreased albumin production. Monitoring for abdominal distention and fluid
accumulation is essential for assessing the progression of cirrhosis and implementing appropriate interventions.
B. Implement a low-carbohydrate diet - While dietary modifications may be necessary for clients with cirrhosis, such as reducing sodium intake, implementing a low-carbohydrate diet is not typically a primary intervention for cirrhosis.
C. Review serum amylase levels - Serum amylase levels are typically assessed to diagnose pancreatitis, which is not directly related to cirrhosis unless complications such as alcoholic pancreatitis are present.
D. Place warm compresses on areas of pruritus - Pruritus (itching) is a common symptom of liver disease, including cirrhosis, due to bile salt accumulation. While warm compresses may provide
temporary relief, they do not address the underlying cause of pruritus in cirrhosis.
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