A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?

Temperature 38.8° C (101.8° F)

Straw-colored urine

Apical pulse rate 58/min

Blood pressure 158/92 mm Hg

Answer and Explanation

The Correct Answer is A

The correct answer is: a. Temperature 38.8° C (101.8° F)

Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.

Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.

Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.

Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.

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Correct Answer is C

Explanation

Assessing the client's ability to use the call light is crucial for their safety and well-being. If the client is unable to use the call light to request assistance, it increases the risk of falls or accidents when they attempt to move or perform tasks without assistance. By determining the client's ability to use the call light, the nurse can ensure that appropriate measures are in place to enable the client to call for help whenever needed.

Applying rubber-soled slippers before ambulation helps to provide better traction and reduce the risk of slips and falls, but it can be implemented after assessing the client's ability to use the call light.

Moving the bedside table closer to the bed is helpful for the client to access personal items without the need to reach or stretch, but it is not the highest priority among the given options.

Creating a schedule with assistive personnel for hourly rounding is important for regular checks on the client's safety and well-being, but it can be arranged after assessing the client's ability to use the call light.

A. Place the shoulder harnesses at the level of the infant's shoulders. B. Position the car seat at a 90° angle. C. Put a small cushion under the newborn's head for support. D. D. Keep the airbag on if the car seat is in the front seat.

Correct Answer is A

Explanation

The shoulder harnesses of the car seat should be positioned at or slightly below the level of the infant's shoulders. This helps secure the infant properly in the car seat and provides appropriate protection in the event of a crash.

Car seats for infants should not be positioned at a 90° angle. Instead, they should be installed at a reclined angle, as recommended by the car seat manufacturer. The specific recline angle can vary depending on the car seat model and the age of the child.

Additional cushions or support devices should not be placed in the car seat unless specifically recommended by the car seat manufacturer. Extra padding or cushions can interfere with the proper fit of the harness and compromise the safety of the infant.

It is not safe to have an infant's car seat in the front seat if there is an active airbag. The safest place for an infant's car seat is in the rear seat, preferably in the middle position. If the car does not have a rear seat, it is important to disable the airbag if the car seat must be placed in the front seat.

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A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?

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