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.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. It's important to include the complete name of the medication to ensure clarity and accuracy in documentation.
B. Omitting the leading zero before a decimal point can lead to medication errors, so it's important to include it.
C. "U" is commonly used to denote units when documenting insulin dosage, so this statement is accurate.
D. "QOD" is an outdated abbreviation and can lead to confusion, so it should not be used; instead, "every other day" should be written out for clarity.
Correct Answer is B
Explanation
A. Cannabis withdrawal typically presents with symptoms such as irritability, anxiety, insomnia, decreased appetite, and physical discomfort, but not constricted pupils, delayed reflexes, and decreased blood pressure.
B. Opioid intoxication can cause constricted pupils (miosis), delayed reflexes, and decreased blood pressure, among other symptoms such as respiratory depression, drowsiness, and altered mental status.
C. Amphetamine intoxication typically presents with symptoms such as dilated pupils, increased blood pressure, tachycardia, agitation, and hallucinations, but not constricted pupils, delayed reflexes, and decreased blood pressure.
D. Alcohol withdrawal typically presents with symptoms such as tremors, anxiety, agitation, hallucinations, increased heart rate and blood pressure, but not constricted pupils, delayed reflexes, and decreased blood pressure.
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