A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team?

Rationale:

A. The client's lung sounds remain clear during the transfusion: Clear lung sounds indicate the absence of fluid overload or pulmonary complications, which is a safety indicator, but it does not reflect the effectiveness of the transfusion in improving oxygen-carrying capacity.

B. The client's blood pressure increases to 140/85 mm Hg following the transfusion: A sudden rise in blood pressure could indicate fluid overload or a transfusion reaction, not necessarily a positive response to the transfusion.

C. The client's hemoglobin level increases following the transfusion: An increase in hemoglobin indicates that the transfused red blood cells have effectively raised the client’s oxygen-carrying capacity, demonstrating a positive therapeutic response.

D. The client is afebrile during the transfusion: Remaining afebrile indicates the absence of a febrile transfusion reaction, which is a safety measure, but it does not show that the transfusion achieved its therapeutic goal.

Rationale for correct choices:

• Endoscopy: The client presents with a history of gnawing epigastric pain, one episode of dark, tarry stool, hypotension, tachycardia, and significant anemia. These findings suggest possible upper gastrointestinal bleeding or peptic ulcer disease. Endoscopy is the definitive diagnostic procedure to identify the source of bleeding and assess ulcer severity.
• Stool test results: The positive hemoccult (tarry stool) indicates gastrointestinal bleeding. This abnormal finding provides objective evidence that warrants further diagnostic evaluation through endoscopy to prevent further blood loss and complications.

Rationale for incorrect choices:

• Antibiotic prescription: While H. pylori infection can require antibiotics, this client’s immediate concern is gastrointestinal bleeding, not infection control. Antibiotics would not address the urgent need to identify and manage the bleeding source.
• Proton pump inhibitor therapy: Proton pump inhibitors help reduce gastric acid and promote ulcer healing, but initiating therapy alone does not evaluate or stop potential active bleeding. Endoscopy is needed first for diagnostic and possible therapeutic intervention.
• Hypotension: Although hypotension is present, it is a clinical sign of potential blood loss rather than a direct diagnostic criterion. It supports the urgency for endoscopy but is not the primary evidence for the procedure.
• Positive H. pylori test: While H. pylori infection contributes to ulcer formation, the acute presentation of bleeding evidenced by positive hemoccult stool makes the stool test a more immediate indicator for endoscopy.