A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction?

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.

Choice A reason: Blood pressure 160/94 mm Hg is not a reason to withhold atenolol, as it is a beta-blocker that lowers blood pressure and reduces the workload of the heart. Atenolol is indicated for hypertension, angina, and arrhythmias. The nurse should administer atenolol as prescribed, unless the blood pressure is too low (hypotension).

Choice B reason: Heart rate 46/min is a reason to withhold atenolol, as it is a sign of bradycardia (slow heart rate), which can be a side effect of atenolol. Atenolol can decrease the heart rate by blocking the beta-1 receptors in the heart. The nurse should withhold atenolol if the heart rate is below 60 beats per minute or above 100 beats per minute, and report the finding to the provider.

Choice C reason: Oxygen saturation 95% is not a reason to withhold atenolol, as it is a normal value that indicates adequate oxygenation of the blood. Atenolol does not affect the oxygen saturation or the respiratory function. The nurse should monitor the oxygen saturation regularly, and report any signs of hypoxia (low oxygen level).

Choice D reason: Respiratory rate 18/min is not a reason to withhold atenolol, as it is a normal value that indicates normal breathing. Atenolol does not affect the respiratory rate or the respiratory function. The nurse should monitor the respiratory rate regularly, and report any signs of dyspnea (difficulty breathing).