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 {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

A. To best hear the closing of the aortic heart valve, the nurse should place the diaphragm of the stethoscope at the second intercostal space, right sternal border. This is also known as the aortic area.
B. This is the tricuspid region, and defects with the tricuspid valve will be best heard in this area.
C. This is the mitral region and murmurs due to defects in the mitral valve will be appreciated here

A. Add the contents of the capsules to food. B. Dissolve the capsules in a glass of chocolate milk. C. Administer the medication with a glass of orange juice. D. Administer the medication at bedtime.

Correct Answer is C

Explanation

A. Mixing ferrous sulfate capsules with food may alter the absorption of the medication. It is generally recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce

irritation.

B. Dissolving ferrous sulfate capsules in chocolate milk or any other liquid may affect the taste and consistency of the drink. Additionally, chocolate milk may contain substances that could

interfere with iron absorption.

C. Administering iron supplements with a glass of orange juice is a common recommendation because vitamin C enhances the absorption of iron. This combination helps improve the bioavailability of the iron supplement.

D. There is no specific indication to administer ferrous sulfate capsules at bedtime. It is typically recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce irritation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

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Correct Answer is C

Explanation

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