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:

Wearing a lead apron when providing client care is appropriate. When caring for a client who is receiving internal radiation therapy, the nurse should take appropriate safety measures to minimize their exposure to radiation. Wearing a lead apron when providing care to the client helps shield the nurse's body from radiation exposure and reduces the risk of harm.

Choice B Reason:

Allowing visitors to hold the client's hand is inappropriate. Visitors should also be educated about radiation safety measures and should not be encouraged to have close contact with the client during internal radiation therapy.

Choice C Reason:

Leaving the door to the client's room open is inappropriate. Closing the door to the client's room can help contain radiation and limit its spread to other areas.

Choice D Reason:

Placing the dosimeter badge on the client's bed is inappropriate. The dosimeter badge should be worn by healthcare personnel to measure their radiation exposure. Placing it on the client's bed does not accurately measure the nurse's exposure and is not the correct use of the badge.

Choice A Reason:

Changing the catheter dressing daily - While it's important to maintain the dressing and keep it clean and dry, changing the dressing daily might not be necessary. The dressing should be changed according to facility policy and based on assessment findings.

Choice B Reason:

Cleaning the insertion site using 20 mL of hydrogen peroxide - Hydrogen peroxide is not recommended for cleaning PICC line insertion sites, as it can cause tissue irritation. The insertion site should be cleaned with an appropriate antiseptic solution per facility guidelines.

Choice C Reason:

Use a 10-mL syringe to flush the line. When completing discharge teaching for a client with a peripherally inserted central catheter (PICC) line, the nurse should include instructions regarding the proper care of the line. Using a 10-mL syringe to flush the line is the appropriate practice to prevent excessive pressure within the catheter and minimize the risk of catheter damage or rupture.

Choice D Reason:

Not elevating the arm above the level of the heart - Elevation of the arm above the heart level is generally not contraindicated for a PICC line. However, it's important to avoid activities that could lead to kinking or pulling on the line. The nurse should provide specific instructions regarding arm movement and care to the client.