A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make?

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: Using IV tubing specific for heparin sodium when administering the infusion is not the correct action. Heparin sodium can be administered using any standard IV tubing, as long as it is primed with heparin solution to prevent clotting in the tubing.

Choice B reason: Administering 50,000 units of heparin by IV bolus every 12 hours is not the correct action. This is a very high dose of heparin that can cause bleeding complications. The usual dose of heparin for continuous IV infusion is 15 to 25 units/kg/hour, adjusted according to the aPTT results.

Choice C reason: Having vitamin K available on the nursing unit is not the correct action. Vitamin K is the antidote for warfarin, not heparin. Vitamin K reverses the effects of warfarin by increasing the synthesis of clotting factors in the liver.

Choice D reason: Checking the activated partial thromboplastin time (aPTT) every 4 hours is the correct action. The aPTT is a blood test that measures the time it takes for the blood to clot. It is used to monitor the effectiveness and safety of heparin therapy. The therapeutic range of aPTT for heparin is 1.5 to 2.5 times the normal value, or 60 to 80 seconds. The nurse should check the aPTT every 4 hours until it is within the therapeutic range, and then every 6 to 8 hours thereafter. The nurse should adjust the heparin infusion rate according to the aPTT results and the prescriber's orders.