A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing a hemolytic reaction?

Choice A reason: The nurse collects a urine specimen is an appropriate action, as it can help detect the presence of hemoglobinuria, which is a sign of hemolysis. Hemoglobinuria is the excretion of hemoglobin in the urine, which can cause the urine to appear red or brown.

Choice B reason: The nurse sends a blood specimen to the laboratory is an appropriate action, as it can help confirm the diagnosis of a hemolytic reaction and identify the cause. The laboratory can perform tests such as blood typing, cross-matching, direct antiglobulin test (DAT), and serum bilirubin.

Choice C reason: The nurse initiates an infusion of 0.9% sodium chloride is an appropriate action, as it can help maintain the client's fluid and electrolyte balance and prevent hypovolemic shock. 0.9% sodium chloride is the preferred solution for blood transfusion reactions, as it is isotonic and compatible with blood products.

Choice D reason: The nurse starts the transfusion of another unit of blood product is an inappropriate action, as it can worsen the client's condition and increase the risk of complications. The nurse should not resume the transfusion until the cause of the reaction is determined and the provider orders a new unit of blood product. The nurse should also return the unused blood product and tubing to the blood bank for analysis.

Choice A reason: Removing the patch for 10 to 12 hours daily is a correct instruction. This allows the client to have a nitrate-free period, which prevents the development of tolerance to the medication. Tolerance reduces the effectiveness of nitroglycerin in relieving anginal pain. The client should remove the patch at night, when the risk of angina is lower, and apply a new patch in the morning.

Choice B reason: Applying the patch to a hairless area and rotating sites is a correct instruction. This prevents skin irritation and enhances absorption of the medication. The client should avoid applying the patch to areas that are exposed to heat, sunlight, or friction, as these factors can increase the release of nitroglycerin and cause hypotension.

Choice C reason: Applying a new patch at the onset of anginal pain is not a correct instruction. Transdermal nitroglycerin is used for the prevention, not the treatment, of anginal attacks. The onset of action of transdermal nitroglycerin is slow, and it may take several hours to reach peak effect. The client should use sublingual nitroglycerin, which has a rapid onset of action, to treat acute anginal pain.

Choice D reason: Applying a new patch each morning is a correct instruction. This ensures that the client has a steady and adequate supply of nitroglycerin throughout the day, when the risk of angina is higher. The client should apply the patch to a different site each day, and remove the old patch before applying the new one.

Choice E reason: Applying the patch to dry skin and covering the area with plastic wrap is not a correct instruction. This can cause skin maceration, which is the softening and breaking down of the skin due to moisture. This can increase the risk of infection and reduce the absorption of the medication. The client should apply the patch to clean and dry skin, and avoid covering the area with any dressing or tape.