A nurse is monitoring a client who is receiving 2 units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

Choice A reason:

Measuring the client's blood pressure is appropriate. Assessing the client's blood pressure is a crucial initial step to determine the client's perfusion status and the impact of the bradycardia on their circulation. Sinus bradycardia can result in decreased cardiac output and compromised blood flow to various organs. Measuring the blood pressure helps the nurse evaluate the severity of the bradycardia and its potential effects on the client's overall condition.

Choice B Reason:

Administering atropine to the client is inappropriate. Atropine is a medication that can be used to increase heart rate in bradycardic situations. However, assessing blood pressure comes first to ensure that the blood pressure isn't critically low before administering medications.

Choice C reason:

Initiating IV fluid therapy for the client is inappropriate. Fluid therapy might be necessary to improve perfusion in certain cases, but assessing blood pressure should be done first to guide treatment decisions.

Choice D Reason:

Preparing the client for temporary pacing is inappropriate Temporary pacing might be required in severe cases of bradycardia, but again, assessing blood pressure takes priority to determine the urgency of intervention.

Choice A reason:

A calcium level of 11.5 mg/dL is elevated. Normal calcium levels typically range from 8.5 to 10.5 mg/dL. Hypercalcemia can lead to various complications, including cardiac arrhythmias and neurological symptoms. The nurse should notify the provider of this finding for further evaluation and management.

Choice B reason

Serum albumin level 3.9 g/dL is not appropriate. This level is within a reasonable range for serum albumin. It might be an indicator of nutritional status, but it's not an urgent concern.

Choice C reason:

Output exceeding intake over a 12-hour period may indicate fluid imbalance or inadequate intake compared to output. However, without further context, such as the client's overall fluid status, this finding alone may not be alarming. The nurse should assess the client's hydration status, consider potential causes of increased output, and address any concerns accordingly. While the nurse may need to monitor closely and address any potential issues, immediate notification of the provider may not be necessary based solely on this finding.

Choice D reason:

Fasting blood glucose level 105 mg/dL is not appropriate: A fasting blood glucose level of 105 mg/dL is slightly elevated, but it's not a critically high value. The nurse should monitor blood glucose levels and collaborate with the healthcare team to manage blood glucose appropriately.

However, if the client has a history of diabetes or if there are other concerning factors, such as consistent high glucose levels or symptoms of hyperglycemia, the nurse may need to monitor closely and notify the provider for further evaluation and management. Otherwise, this finding alone may not warrant immediate notification.