A nurse is performing a vision screening for a client. Which of the following findings should the nurse identify as an indication that the client has cataract?

A. Infuse 0.9% sodium chloride IV: The first action in a suspected hemolytic transfusion reaction is to stop the blood transfusion and maintain IV access with 0.9% sodium chloride. This helps prevent hypotension, supports renal perfusion, and allows for administration of fluids to reduce the risk of acute kidney injury from hemolyzed red blood cells.

B. Administer an antipyretic: While fever may occur during a hemolytic reaction, administering an antipyretic is not the priority. Immediate supportive measures, including stopping the transfusion and maintaining IV access, take precedence to prevent severe complications.

C. Decrease the infusion rate to 75 mL/hr: Slowing the transfusion is unsafe in the setting of a hemolytic reaction because the transfusion itself is causing a potentially life-threatening response. The infusion must be stopped entirely, not slowed.

D. Place the client in a left lateral position: Positioning may be used in certain emergencies, such as to prevent aspiration or improve hemodynamics, but it is not a specific intervention for hemolytic transfusion reactions. The priority is to stop the transfusion and initiate fluid resuscitation.

A. Schedule routine oral suctioning: Suctioning can increase intracranial pressure and should be performed only when necessary, using short, gentle passes. Routine suctioning is not recommended for a child with increased ICP, as it can exacerbate neurological injury.

B. Pad the side rails of the bed: An unresponsive child is at high risk for injury from involuntary movements or seizures. Padding the side rails helps prevent trauma and is a key safety intervention in children with increased intracranial pressure, making it the priority action in this scenario.

C. Obtain isolation supplies: Isolation precautions are only needed if the child has a contagious condition. Increased intracranial pressure does not automatically indicate a risk of infection transmission, so isolation supplies are not immediately necessary.

D. Place the child in Trendelenburg position: Trendelenburg positioning (head-down) can further increase intracranial pressure and is contraindicated. Children with elevated ICP should be positioned with the head of the bed elevated to promote venous drainage and reduce pressure.