A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

Infuse 0.9% sodium chloride IV.

Administer an antipyretic.

Decrease the infusion rate to 75 mL/hr.

Place the client in a left lateral position.

Answer and Explanation

The Correct Answer is A

A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop

the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.

B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.

C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.

D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "Rub your child's gums with an aspirin tablet before bedtime." - Aspirin is not recommended for children due to the risk of Reye's syndrome, a potentially fatal condition.

B. "Place an amber teething necklace on your child before bedtime." - Amber teething necklaces pose a choking hazard and are not recommended for infants.

C. "Administer acetaminophen drops to your child before bedtime." - Acetaminophen is a safe and effective pain reliever for infants and can help alleviate discomfort associated with teething, which may improve sleep.

D. "Apply a teething product containing benzocaine to your child's gums before bedtime." -

Benzocaine-containing products are not recommended for infants due to the risk of methemoglobinemia, a potentially life-threatening condition.

A. Eggs B. Latex C. Peanuts D. Iodine

Correct Answer is D

Explanation

A. Allergies to eggs are not typically a contraindication for a thyroid scan.

B. Latex allergies are not typically a contraindication for a thyroid scan unless latex-containing materials are involved in the procedure, such as gloves or adhesive bandages.

C. Allergies to peanuts are not typically a contraindication for a thyroid scan.

D. Iodine is the main component of the radioactive tracer used in a thyroid scan. If the client has a known allergy to iodine, it would be unsafe for them to undergo the scan.

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