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: Taking only one dose of nitroglycerin is not a good advice, as it may not be enough to relieve the angina pain and prevent a myocardial infarction. Nitroglycerin is a vasodilator that relaxes the blood vessels and improves the blood flow to the heart. The recommended dose is one tablet or spray under the tongue every 5 minutes for up to three doses, or until the pain is relieved. Taking only one dose may compromise the effectiveness of the medication and the safety of the client.

Choice B reason: Asking the provider to prescribe a different medication is not a necessary action, as nitroglycerin is a first-line treatment for stable angina and has proven benefits for reducing mortality and morbidity. Changing the medication may not be appropriate or feasible, as there may not be a suitable alternative that has the same efficacy and safety profile. The client should continue taking nitroglycerin as prescribed, unless the provider decides otherwise.

Choice C reason: Saying that there's nothing that can be done to relieve the headaches is not a true or helpful statement, as there are some measures that can help reduce or prevent the headaches. Headaches are a common and expected side effect of nitroglycerin, as it dilates the blood vessels in the brain and causes increased intracranial pressure. However, the headaches usually subside over time as the body adapts to the medication. The client can also take a mild analgesic, such as acetaminophen or ibuprofen, to relieve the headache, as long as it does not interact with the nitroglycerin or other medications.

Choice D reason: Trying to take a mild analgesic to relieve the headache is a reasonable and appropriate suggestion, as it can help alleviate the discomfort and improve the quality of life of the client. The client should choose an analgesic that is safe and effective, such as acetaminophen or ibuprofen, and follow the directions on the label. The client should also consult the provider or the pharmacist before taking any over-the-counter medications, as some of them may interact with nitroglycerin or other medications. The client should also avoid aspirin, as it may increase the risk of bleeding.

Choice A reason: Weighing the client is not a necessary action before administering digoxin, as it does not affect the dosage or effectiveness of the medication. Weighing the client may be important for monitoring fluid balance and edema, but it is not related to digoxin therapy.

Choice B reason: Measuring the client's blood pressure is not a necessary action before administering digoxin, as it does not affect the dosage or effectiveness of the medication. Digoxin is not a blood pressure-lowering medication, but a cardiac glycoside that increases the contractility and efficiency of the heart. Measuring the blood pressure may be important for monitoring hypertension, but it is not related to digoxin therapy.

Choice C reason: Measuring the client's apical pulse is a necessary action before administering digoxin, as it can help determine the safety and appropriateness of the medication. Digoxin can cause bradycardia (slow heart rate) as a side effect, which can be dangerous and symptomatic. The nurse should check the apical pulse for one full minute and withhold the medication if the pulse is below 60 beats per minute or above 100 beats per minute. The nurse should also report any abnormal or irregular rhythms to the provider.

Choice D reason: Offering the client a light snack is not a necessary action before administering digoxin, as it does not affect the absorption or effectiveness of the medication. Digoxin can be taken with or without food. Offering the client a light snack may be important for maintaining nutrition and hydration, but it is not related to digoxin therapy.