A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session?

A. Incorrect. While some gestures can be helpful in communication, they might not always convey complex medical information accurately.

B. Incorrect. Speaking slowly might not necessarily enhance understanding, especially if the client's primary language is different from the nurse's.

C. Correct. When using an interpreter, the nurse should address the client directly and speak as if they are having a direct conversation with the client.

D. Incorrect. Pausing in the middle of sentences can disrupt the flow of communication and might not facilitate understanding.

Indicated:

Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mmHg: - The client is hypotensive (76/45 mmHg), likely due to acute blood loss anemia from a gastrointestinal (GI) bleed. Adjusting the transfusion rate helps stabilize BP while preventing volume overload.

Stay with the client for the first 15 minutes of the transfusion: The highest risk of a transfusion reaction (e.g., hemolysis, anaphylaxis, febrile reaction) occurs within the first 15 minutes, so the nurse must remain with the client for close monitoring.

Obtain the first unit of packed RBCs from the blood bank: The client’s condition (hypotension, tachycardia, history of melena) suggests GI bleeding and significant blood loss. RBC transfusion is required to restore oxygen-carrying capacity and improve perfusion.

Document the blood product transfusion in the client’s medical records: Proper documentation includes blood product type, volume infused, time started and completed, client response, and any adverse reactions. This ensures compliance with safety protocols.

Not Indicated:

Start an IV bolus of lactated Ringer’s solution: Lactated Ringer’s (LR) is incompatible with blood products because it contains calcium, which can cause clotting in the IV line. Normal saline (0.9% NaCl) should be used instead.