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. Infuse 0.9% sodium chloride IV: The first action in a suspected hemolytic transfusion reaction is to stop the blood transfusion and maintain IV access with 0.9% sodium chloride. This helps prevent hypotension, supports renal perfusion, and allows for administration of fluids to reduce the risk of acute kidney injury from hemolyzed red blood cells.
B. Administer an antipyretic: While fever may occur during a hemolytic reaction, administering an antipyretic is not the priority. Immediate supportive measures, including stopping the transfusion and maintaining IV access, take precedence to prevent severe complications.
C. Decrease the infusion rate to 75 mL/hr: Slowing the transfusion is unsafe in the setting of a hemolytic reaction because the transfusion itself is causing a potentially life-threatening response. The infusion must be stopped entirely, not slowed.
D. Place the client in a left lateral position: Positioning may be used in certain emergencies, such as to prevent aspiration or improve hemodynamics, but it is not a specific intervention for hemolytic transfusion reactions. The priority is to stop the transfusion and initiate fluid resuscitation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Eggs: Egg allergies are not relevant to thyroid scans, as the procedure does not involve egg-derived products. There is no increased risk of reaction during imaging for clients with egg allergy.
B. Latex: Latex allergy is a concern for equipment or supplies that contain latex, but it does not contraindicate a thyroid scan. Precautions can be taken with non-latex alternatives if needed.
C. Peanuts: Peanut allergy is unrelated to the substances used in thyroid scans, including radioactive iodine or contrast materials, and does not increase risk for this procedure.
D. Iodine: Iodine allergy is a contraindication because thyroid scans often involve radioactive iodine or iodine-containing contrast agents. Exposure can trigger severe allergic reactions, making it essential to identify and avoid iodine in clients with known allergy.
Correct Answer is A
Explanation
A. The availability of religious facilities: A windshield survey involves direct observation of the community environment. Observing resources such as religious facilities, schools, parks, and stores provides information about community assets, social support, and infrastructure, which are key factors in assessing community health.
B. Influenza incidence rates for the current year: Incidence rates require access to public health records or databases, not visual observation. This type of epidemiological data is collected through statistical reports, not a windshield survey.
C. The leading cause of death for the prior year: Mortality data are obtained from health department statistics or vital records. This information cannot be gathered through direct community observation and therefore is not part of a windshield survey.
D. Individual perceptions about how residents interact: Perceptions and attitudes require interviews, surveys, or focus groups. A windshield survey captures observable, physical, and environmental characteristics, not subjective opinions, so this information would need other data collection methods.
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