A home health nurse is caring for a client who reports difficulty buttoning their clothes due to neuropathy. Which of the following referrals should the nurse make for the client?

A. Tell the client, "You seem to be very upset.": Using verbal de-escalation and acknowledging the client’s emotions can help reduce agitation. This approach demonstrates empathy, promotes communication, and can prevent escalation.

B. Use a face shield with a mask when providing care to the client: Personal protective equipment is important for infection control, but it does not address the behavioral escalation or help calm an agitated client.

C. Initiate seclusion protocol: Seclusion is a restrictive intervention used only if the client poses an imminent risk of harm. It is not the first step in managing agitation and should follow attempts at de-escalation.

D. Engage the panic alarm: Activating the panic alarm is appropriate in situations of immediate danger, but for verbal agitation and pacing without aggression, de-escalation is the first intervention.

Rationale:

A. Obtain filterless IV tubing: Blood transfusions require specialized IV tubing with an in-line filter to remove clots and debris. Using filterless tubing would increase the risk of transfusing particulate matter into the client’s bloodstream.

B. Place the blood in a warmer for 1 hr: Blood should only be warmed if specifically prescribed and done using an approved device immediately before administration. Prolonged warming increases the risk of bacterial growth and hemolysis.

C. Use a 24-gauge IV catheter: Packed RBCs should be administered through a larger-bore catheter (typically 18–20 gauge) to allow adequate flow and prevent hemolysis. A 24-gauge catheter is too small for efficient transfusion.

D. Prime IV tubing with 0.9% sodium chloride: Normal saline is the only compatible solution for priming and administering blood products. It prevents clotting and hemolysis while ensuring that the blood flows freely without interacting with other IV solutions.