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 A

Explanation

A. Ventrogluteal - The ventrogluteal site is preferred for intramuscular injections in adults due to its proximity to large, deep muscles and minimal risk of injury to major nerves and blood vessels.

B. Dorsogluteal - The dorsogluteal site is not recommended for intramuscular injections due to the risk of injury to the sciatic nerve and superior gluteal artery.

C. Vastus lateralis - The vastus lateralis is a safe site for intramuscular injections, particularly in infants and young children.

D. Rectus femoris - The rectus femoris muscle is not typically used for intramuscular injections due to its superficial location and proximity to major blood vessels.

A. Clothe the newborn in light cotton. B. Check the newborn's temperature every 8 hr. C. Administer 120 mL (4 oz) of water between feedings. D. Place the newborn 45 cm (18 in) from the light source.

Correct Answer is D

Explanation

- A. Clothing the newborn in light cotton is not recommended because it can block the light from reaching the skin, which is necessary for the treatment of hyperbilirubinemia through phototherapy.
- B. Checking the newborn's temperature every 8 hours is not frequent enough; during phototherapy, it is important to monitor the newborn's temperature more frequently to ensure they do not become too cold or too warm as a result of the therapy.
- C. Administering water between feedings is not recommended as it can interfere with the newborn's feeding schedule and nutrition; breast milk or formula provides adequate hydration unless otherwise indicated by a healthcare provider.
- D. Placing the newborn 45 cm (18 in) from the light source is the correct intervention. This distance allows for optimal exposure to the light while ensuring the safety and comfort of the newborn, as recommended in clinical guidelines for effective phototherapy.

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