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.

Answer and Explanation

The Correct Answer is 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.

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Correct Answer is B

Explanation

A. Using the injection port farthest from the IV catheter insertion site is not necessary for administering an IV bolus of medication and may not be practical depending on the setup of the IV tubing.

B. Occluding the IV tubing above the injection port prevents the bolus medication from flowing into the continuous IV infusion, ensuring that the medication is delivered directly to the patient.

C. Checking for blood return after medication administration is not relevant in this context, as albumin 5% is administered intravenously and does not require blood return.

D. Flushing the IV tubing with a heparinized solution is not necessary for administering an IV bolus of medication and may not be appropriate for all medications.

A. Metoprolol B. Clopidogrel C. Metformin D. Digoxin

Correct Answer is C

Explanation

A. Metoprolol is a beta-blocker used to treat hypertension and other cardiovascular conditions.

While it may be important for the provider to be aware of all medications, it is not the priority to report in this scenario.

B. Clopidogrel is an antiplatelet medication used to prevent blood clots in individuals at risk for cardiovascular events. While it may have implications for the procedure, it is not the priority to report in this scenario.

C. Metformin is an oral antidiabetic medication commonly used to treat type 2 diabetes. It is

important to report because there may be specific considerations regarding its use in the context of a colonoscopy, such as the risk of lactic acidosis.

D. Digoxin is a medication used to treat heart failure and certain arrhythmias. While it may have implications for the procedure, it is not the priority to report in this scenario.

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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?

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