A nurse is admitting a client who has major depressive disorder. Which of the following actions should the nurse take during the orientation phase of the therapeutic relationship?

A. A client who has gastroenteritis and is lethargic and confused: Lethargy and confusion indicate significant fluid and electrolyte imbalances, possibly severe dehydration, which can rapidly become life-threatening. Gastroenteritis can cause profound fluid loss, and these neurological changes suggest urgent intervention is needed to prevent shock or other complications.

B. A client who has cystic fibrosis, has a thick, productive cough and reports thirst: Thick secretions and thirst are expected concerns in cystic fibrosis due to chronic pulmonary involvement and potential dehydration. While important to address, these symptoms are less immediately life-threatening compared to altered mental status.

C. A client who has sickle cell anemia and reports pain 15 min after receiving analgesic: Pain is a common and expected symptom in sickle cell crises. The client may require additional pain management, but this finding does not indicate immediate life-threatening issues. The nurse can prioritize this after addressing the client with altered mental status.

D. A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL: This elevated glucose requires monitoring and possible adjustment of treatment but is not acutely life-threatening. Hyperglycemia of this level can be managed according to the provider’s plan, so it is not the highest priority for immediate reporting.

A. Infuse 0.9% sodium chloride IV: The first action in a suspected hemolytic transfusion reaction is to stop the blood transfusion and maintain IV access with 0.9% sodium chloride. This helps prevent hypotension, supports renal perfusion, and allows for administration of fluids to reduce the risk of acute kidney injury from hemolyzed red blood cells.

B. Administer an antipyretic: While fever may occur during a hemolytic reaction, administering an antipyretic is not the priority. Immediate supportive measures, including stopping the transfusion and maintaining IV access, take precedence to prevent severe complications.

C. Decrease the infusion rate to 75 mL/hr: Slowing the transfusion is unsafe in the setting of a hemolytic reaction because the transfusion itself is causing a potentially life-threatening response. The infusion must be stopped entirely, not slowed.

D. Place the client in a left lateral position: Positioning may be used in certain emergencies, such as to prevent aspiration or improve hemodynamics, but it is not a specific intervention for hemolytic transfusion reactions. The priority is to stop the transfusion and initiate fluid resuscitation.