A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?

Choice A reason: Reorienting to day and time frequently is a nursing intervention that the nurse should implement, because it can help the client to reduce confusion, anxiety, and disorientation, which may contribute to the auditory hallucinations. The nurse should use simple and clear language, speak slowly and calmly, and provide cues and reminders, such as a clock, a calendar, or a picture, to help the client to orient to reality.

Choice B reason: Applying soft wrist restraints bilaterally is not a nursing intervention that the nurse should implement, unless it is absolutely necessary and ordered by the doctor. Restraints can increase the client's agitation, anxiety, and fear, and they can also cause physical and psychological harm, such as skin breakdown, nerve damage, or loss of dignity. The nurse should use restraints only as a last resort, after trying other less restrictive alternatives, such as verbal de-escalation, distraction, or medication.

Choice C reason: Administering a PRN dose of lorazepam is a nursing intervention that the nurse should implement, if it is prescribed by the doctor and indicated by the client's condition. Lorazepam is a benzodiazepine that can help the client to relax, reduce anxiety, and sedate the central nervous system, which may alleviate the auditory hallucinations. The nurse should monitor the client's vital signs, level of consciousness, and respiratory status, and report any adverse effects, such as hypotension, bradycardia, or respiratory depression.

Choice D reason: Turning the television on for distraction is not a nursing intervention that the nurse should implement, because it can worsen the client's auditory hallucinations, confusion, and agitation. The television can provide too much stimulation, noise, and information, which can overload the client's sensory perception and interfere with their ability to distinguish reality from hallucination. The nurse should provide a quiet and calm environment, and limit the sources of auditory input.

Choice E reason: Presenting a calm, supportive demeanor is a nursing intervention that the nurse should implement, because it can help the client to feel safe, comfortable, and respected, and to establish a trusting relationship with the nurse. The nurse should show empathy, compassion, and patience, and avoid arguing, criticizing, or dismissing the client's hallucinations. The nurse should acknowledge the client's feelings, validate their distress, and reassure them that they are not alone.

Choice A reason: Clear, dark amber-colored urine is not a sign of improvement for a client with cirrhosis and hepatic failure. It may indicate dehydration, which can worsen the condition of the liver and kidneys. The client should be encouraged to drink enough fluids to maintain hydration and urine output.

Choice B reason: Improved level of consciousness is a positive sign for a client with cirrhosis and hepatic failure, but it is not directly related to the treatment plan of low sodium diet and albumin infusions. It may indicate a reduction in ammonia levels, which can cause hepatic encephalopathy, a condition that affects the brain function. The client should be monitored for signs of mental status changes, such as confusion, lethargy, or coma.

Choice C reason: Prothrombin time within normal limits is also a good sign for a client with cirrhosis and hepatic failure, but it is not the main goal of the treatment plan of low sodium diet and albumin infusions. It may indicate an improvement in the liver's ability to produce clotting factors, which can prevent bleeding complications. The client should be checked for signs of bleeding, such as bruising, petechiae, or hematemesis.

Choice D reason: Decreased abdominal girth is the best indicator of progress toward the desired effect of the treatment plan of low sodium diet and albumin infusions. It means that the client has reduced fluid retention and ascites, which are common complications of cirrhosis and hepatic failure. The client should be measured for abdominal girth daily, and weighed regularly, to monitor the fluid status.