A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

C. Double vision.Double vision, or diplopia, can indicatephenytoin toxicity, which is a serious condition that may lead to impaired vision and increased risk of falls or injuries. This side effect suggests that the patient may be experiencing adverse reactions to the medication, necessitating prompt evaluation and intervention, such as checking serum phenytoin levels and possibly adjusting the medication regimen

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.The other options do not require immediate intervention:

• A. Chronic insomniais not a critical side effect of phenytoin and may be managed with lifestyle modifications or further assessment.
• B. Puffy, bleeding gumsare common side effects associated with phenytoin (gingival hyperplasia) but are not immediately life-threatening.
• D. Blood pressure 100/78 mm Hgis within normal limits and does not indicate a need for urgent action

Choice A rationale
Checking the fingerstick glucose level is an immediate action that the nurse should take when a patient with type 2 diabetes reports feeling weak and jittery. These symptoms could indicate hypoglycemia, a condition characterized by low blood sugar levels.
Choice B rationale
Assessing skin temperature and moisture can help the nurse determine if the patient is sweating, a common symptom of hypoglycemia.
Choice C rationale
Administering a PRN dose of regular insulin is not the appropriate action if the patient is experiencing symptoms of hypoglycemia. Insulin would further lower the patient’s blood sugar levels, potentially worsening their condition.
Choice D rationale
Documenting anxiety on the surgical checklist may not be immediately helpful in addressing the patient’s current symptoms. While it’s important to document all relevant information, the nurse’s immediate focus should be on assessing and managing the patient’s symptoms.
Choice E rationale
Measuring pulse and blood pressure can provide important information about the patient’s cardiovascular status. Hypoglycemia can cause tachycardia and potentially hypotension, so these vital signs should be monitored.