A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

A. A client who is 3 hr post Foley catheter removal and has not voided - While this may require assessment, it is not as urgent as assessing a client with potentially significant respiratory complications.

B. A client who is 3 days postoperative colectomy with a large, loose melena stool - While melena may indicate gastrointestinal bleeding, the client is not actively experiencing a respiratory issue.

C. A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 - Pain is important to address, but it is not as urgent as respiratory distress.

D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - Pink-tinged sputum may indicate bleeding from the respiratory tract, which could be a complication of the procedure and requires immediate assessment and intervention.

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.