A nurse assesses four patients. Which patient has greatest risk for hypomagnesemia?

A. Prime the blood tubing with dextrose 5% in water:
Priming the blood tubing with dextrose 5% in water is not appropriate for a blood transfusion. Blood tubing should be primed with normal saline, not dextrose solutions, to prevent hemolysis of the blood components.
B. Check vital signs before transfusion:
Before initiating a blood transfusion, it's essential to assess the client's vital signs, including temperature, pulse, respiratory rate, and blood pressure. Monitoring vital signs before, during, and after the transfusion helps identify any adverse reactions promptly.
C. Insert an IV with a 13-gauge needle:
Using a 13-gauge needle for IV insertion is not appropriate for a blood transfusion. Typically, a smaller gauge needle, such as 18 or 20 gauge, is used for venous access during a blood transfusion to minimize discomfort and reduce the risk of hemolysis.
D. Transfuse the blood product within 5 hr after removing it from refrigeration:
Blood products should be transfused within a specific timeframe after removal from refrigeration to minimize the risk of bacterial growth and subsequent infection. Typically, this timeframe is within 4 hours for packed red blood cells and within 24 hours for platelets. Adhering to the recommended timeframe ensures the safety and efficacy of the transfusion.
E. Check the expiration date of the blood product with a second nurse:
Verifying the expiration date of the blood product with a second nurse or healthcare provider is a crucial step to ensure patient safety and prevent the administration of expired blood products. This double-check process helps mitigate the risk of administering outdated or expired blood components.

A. Turn the client on his side before starting oral care: This is the correct action. Turning the client on their side helps prevent aspiration of oral secretions or fluids during oral care, especially for an immobile client who may have difficulty swallowing or managing oral secretions effectively. Positioning the client on their side also facilitates better access to the oral cavity for oral care procedures.

B. Use the thumb and index finger to keep the client's mouth open: Using the thumb and index finger to keep the client's mouth open may cause discomfort or injury to the client. Instead, it's essential to encourage the client to open their mouth gently or use an appropriate oral device to keep the mouth open during oral care.

C. Apply petroleum jelly to the client's lips after oral care: Applying petroleum jelly to the client's lips after oral care can help keep the lips moisturized and prevent dryness. However, it is not the most immediate action necessary for oral care. Ensuring proper positioning and cleaning of the oral cavity take precedence during oral care for an immobile client.

D. Use a stiff toothbrush to clean the client's teeth: Using a stiff toothbrush can cause damage to the client's oral tissues, especially if the client has impaired oral hygiene or compromised oral health. It's essential to use a soft-bristled toothbrush or sponge swabs for oral care to prevent injury or trauma to the oral mucosa, especially in clients who are immobile.