A nurse is monitoring a client who is receiving 2 units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

B. Potassium level: The normal potassium range is 3.5 to 5 mEq/L. The client's potassium level of 5.0 mEq/L is at the upper end of the normal range. While it is within the normal range, it is important to monitor it closely since elevated potassium levels can lead to cardiac dysrhythmias. Therefore, this finding indicates a need for follow-up by the nurse.

D. Urinary output: Urinary output is an important indicator of renal function and fluid balance. If the urinary output is significantly decreased or too low, it could indicate issues with kidney function or inadequate fluid intake. Monitoring urinary output is essential to assess the client's hydration status and kidney function. Therefore, this finding indicates a need for follow-up by the nurse.

Incorrect answers:

A. Blood pressure: Blood pressure is not indicated in the provided laboratory results. It is important to monitor blood pressure, but the information provided does not suggest any abnormality related to blood pressure.

C. Respiratory rate: Respiratory rate is not indicated in the provided laboratory results. It is important to monitor respiratory rate, but the information provided does not suggest any abnormality related to respiratory rate.

E. Heart rate: Heart rate is not indicated in the provided laboratory results. It is important to monitor heart rate, but the information provided does not suggest any abnormality related to heart rate.

F. Temperature: Temperature is not indicated in the provided laboratory results. It is important to monitor temperature, but the information provided does not suggest any abnormality related to temperature.

G. Oxygen saturation: Oxygen saturation is not indicated in the provided laboratory results. It is important to monitor oxygen saturation, but the information provided does not suggest any abnormality related to oxygen saturation.

H. Skin assessment: Skin assessment is not indicated in the provided laboratory results. It is important to assess the skin, but the information provided does not suggest any abnormality related to skin assessment.

Choice A reason:

May operate a motor vehicle when no longer taking analgesics is appropriate. This option could still potentially be a concern. While the patient might not be taking analgesics, the halo device's restrictions on neck movement could still impact their ability to safely operate a motor vehicle. So, this option might still need clarification with the provider.

Choice B reason:

Increase Intake of fibre-rich foods. This option is not related to the use of a halo device. Increasing fibber intake is generally a positive dietary recommendation, and it doesn't directly pertain to the halo device or the patient's discharge instructions.

Choice C reason:

May place a small pillow under the head when sleeping. This option is incorrect because using a small pillow under the head when sleeping is a common practice for patients with halo devices. It helps to maintain proper alignment and reduce discomfort while sleeping.

Choice D reason:

Take tub baths instead of showers. This option is incorrect because taking tub baths instead of showers is a common recommendation for patients with halo devices. The halo device must be kept dry to prevent complications. Showering might increase the risk of water seeping into the halo vest, whereas taking a tub bath could help in maintaining dryness around the device.