A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?

Rationale:

A. Increased hemoglobin: A rise in hemoglobin is not expected after surgery but also does not suggest a postoperative complication. It may reflect hemoconcentration from mild dehydration or fluid shifts. This finding does not indicate infection, thrombosis, or impaired healing, so it is not a priority concern at this stage.

B. Increased urinary output: Higher urinary output may occur if the client is well-hydrated or receiving IV fluids. This finding does not suggest renal impairment or postoperative complications. As long as urine is clear and the client is stable, increased output is not concerning and requires only routine monitoring.

C. Unilateral leg swelling: One-sided leg swelling is a hallmark sign of deep vein thrombosis, a serious complication after pelvic surgery due to venous stasis and immobilization. A DVT can progress to pulmonary embolism, posing immediate danger. The finding requires prompt evaluation and intervention to prevent life-threatening complications.

D. Mild pain at the surgical site: Mild incisional pain is expected on postoperative day three as tissues heal and inflammation decreases. This finding is typical and manageable with analgesics. As long as pain is not severe or accompanied by fever, redness, or purulent drainage, it does not indicate a complication.

Rationale:

A. Prime the infusion tubing with 0.45% sodium chloride.: Blood products should never be primed with hypotonic solutions like 0.45% sodium chloride because it can cause hemolysis of the RBCs. Only 0.9% sodium chloride (normal saline) is safe for priming and flushing blood administration tubing.

B. Assess the client's lung sounds prior to the infusion.: Older adults are at increased risk for fluid overload during transfusions. Assessing lung sounds before starting the infusion provides a baseline and helps detect early signs of pulmonary edema or transfusion-associated circulatory overload.

C. Verify with another nurse that the unit of blood is compatible with the client's blood type.: Performing a second verification with another nurse is a critical safety measure to prevent transfusion reactions. Confirming blood type and crossmatch ensures compatibility and patient safety.

D. Don sterile gloves to prepare the blood administration setup.: Sterile gloves are not required for blood administration. Standard clean technique with non-sterile gloves is sufficient to prevent infection, as the IV setup does not require sterility.

E. Infuse the blood over 4 hr.: Red blood cells should be infused within 4 hours to minimize the risk of bacterial growth and ensure product viability. Infusing too slowly can increase infection risk, and infusing too quickly can cause fluid overload, especially in older adults.