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 B
Explanation
A. "I should place a rolled blanket along each side of my baby's head in the car seat." - Incorrect. Placing rolled blankets on each side of the baby's head is not recommended as it can increase the risk of suffocation. Infants should be positioned in the car seat without any extra padding or blankets.
B. "I should place my baby's car seat rear-facing until 6 months of age." - Correct. Rear- facing car seats are recommended for infants until they reach at least 2 years of age or until they outgrow the weight and height limits specified by the car seat manufacturer. This position provides the best protection for the baby's head, neck, and spine in the event of a crash.
C. "I should put the car seat retainer clip at the level of my baby's belly button." - Incorrect.
The retainer clip should be positioned at armpit level to secure the harness straps properly.
D. "I should position my baby's car seat at a 90-degree angle in the car." - Incorrect. Car seats should be installed at the appropriate recline angle according to the manufacturer's
instructions, which may vary depending on the specific car seat model and the child's age and size.
Correct Answer is A
Explanation
A.
A. Educating the client on covering the nose and mouth with tissues when coughing helps prevent the spread of tuberculosis by containing respiratory secretions.
B. A client with active tuberculosis should not return to work until they have completed a sufficient duration of treatment and are deemed non-infectious, not solely based on negative sputum cultures.
C. The client remains contagious until they have been on appropriate medication therapy for a sufficient duration and are deemed non-infectious by healthcare providers, usually after several weeks of treatment rather than just one week.
D. While wearing protective masks may be recommended for healthcare workers or individuals with compromised immune systems, it's not necessary for the client's family members unless they are in close contact with the client for an extended period.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today