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?

A. Monitoring the insertion site for infection:
Monitoring for infection is important in the long-term care of a client following cardiac catheterization, but it is not the immediate priority. Infection typically develops over time, not in the immediate postprocedure period.

B. Checking for orthostatic hypotension:
Orthostatic hypotension is not typically associated with cardiac catheterization. Instead, hypotension following the procedure would likely result from bleeding or hypovolemia. Monitoring for vital sign changes is important but not specific to orthostatic hypotension in this context.

C. Forcing fluids:
Encouraging fluids is necessary after cardiac catheterization to help flush out contrast dye and prevent nephropathy. However, this action is not the immediate priority compared to managing the risk of bleeding and maintaining hemostasis at the insertion site.

D. Immobilizing the affected extremity:
Immobilizing the extremity used for catheter insertion (usually the femoral artery) is the immediate priority. This action prevents complications such as bleeding, hematoma formation, or disruption of the arterial puncture site. Maintaining hemostasis and ensuring the integrity of the insertion site are critical during the immediate postprocedure period.

A. Taking the client to the bathroom after a preoperative injection may be unsafe because many preoperative medications can cause sedation or dizziness, increasing the risk of falls.
B. Verification of the surgical site should occur before administration of preoperative medications, as the client may be sedated and unable to participate accurately afterward.
C. Teaching deep breathing and coughing exercises is most effective before sedation, when the client is alert and able to learn and follow instructions.
D. Raising the side rails on the bed is a priority safety measure after administering preoperative sedatives, as it helps prevent falls and injury while the client is drowsy or unsteady.