A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

Choice A rationale:

The nurse should use the client's telephone number or another unique identifier, such as a medical record number or a unique identification code, to confirm the client's identity before administering medication. Using a telephone number or a unique identifier ensures accurate identification of the client and helps prevent medication errors.

Choice B rationale:

Place of birth is not a suitable identifier for confirming a client's identity. It does not provide specific and accurate information about the individual and may not be unique to the client.

Choice C rationale:

Driver license number is not a suitable identifier for confirming a client's identity. It may not be readily available in the healthcare setting, and not all clients have a driver's license. Using this identifier could lead to identification errors.

Choice D rationale:

Room number is not a suitable identifier for confirming a client's identity. Room numbers are not unique to individual clients and can change based on hospital assignments. Relying on room numbers can lead to confusion and medication errors.

Choice A rationale:

Hanging the transfusion with dextrose 5% in 0.9% sodium chloride is incorrect. Packed red blood cells (PRBCs) are transfused with normal saline (0.9% sodium chloride) and not with dextrose-containing solutions. Using dextrose can cause the red blood cells to hemolyze.

Choice B rationale:

Infusing the transfusion over 5 hours is incorrect. PRBC transfusions are typically administered over 2-4 hours, not 5 hours. Infusing the blood too slowly may cause the patient discomfort and may also increase the risk of bacterial growth in the blood product.

Choice C rationale:

Using a 20-gauge IV catheter to transfuse the blood is incorrect. While a 20-gauge IV catheter is suitable for most blood transfusions, it may not be appropriate for older adults or patients with fragile veins. A smaller gauge, such as 22 or 24, might be more suitable to prevent phlebitis and ensure a steady flow without damaging the blood cells.

Choice D rationale:

Monitoring vital signs every hour throughout the transfusion is the correct action. During a blood transfusion, it's crucial to monitor the patient's vital signs frequently to detect any adverse reactions promptly. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, should be assessed before the transfusion, 15 minutes after starting the transfusion, and then hourly thereafter. This vigilant monitoring helps in identifying potential transfusion reactions, such as fever, chills, or hypotension, allowing for immediate intervention if needed.