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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Correct Answer is A

Explanation

- A) Hyperreflexia is a common symptom of opioid withdrawal, as the nervous system reacts to the absence of the drug. Patients may experience increased reflex actions and muscle spasms due to the sudden change in opioid levels.
- B) Meiosis, or pupil constriction, is not typically a withdrawal symptom; it is more commonly associated with opioid use. During withdrawal, pupils are likely to dilate rather than constrict.
- C) Euphoria is a feeling of intense happiness or excitement, which is often experienced after taking opioids. During withdrawal, individuals are more likely to experience dysphoria, which is a state of unease or dissatisfaction.
- D) Hypothermia is not a recognized symptom of opioid withdrawal. Instead, individuals may experience fever or chills as the body adjusts to the lack of opioids.

A. Determine the client's pain level. B. Irrigate the wound with 0.9% sodium chloride irrigation. C. Apply skin preparation to wound edges. D. Don sterile gloves.

Correct Answer is A

Explanation

A. Assessing the client's pain level is the first step to ensure appropriate pain management during the procedure.

B. Irrigating the wound comes after assessing the client's pain level and preparing the wound for the dressing change.

C. Applying skin preparation to wound edges is part of the preparation process but should come after assessing the client's pain level.

D. Donning sterile gloves is necessary for the procedure but should come after assessing the client's pain level.

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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?

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