A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider?

Rationale:

B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.

D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.

C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.

A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.

Rationale for indicated actions:

• Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: The nurse should follow the ordered transfusion rate and not titrate it based on blood pressure. The priority is to transfuse the blood safely and at the prescribed rate, while monitoring the client's response. Blood pressure will improve as the blood volume is restored.
• Obtain the first unit of packed RBCs from the blood bank: This is necessary to correct the client’s anemia (Hgb 9.1 g/dL, Hct 27%) and address the suspected acute blood loss indicated by positive hemoccult stool and hemodynamic changes.
• Document the blood product transfusion in the client's medical record: Accurate documentation ensures legal compliance, tracks the administration, and records the client’s response, including any adverse events, supporting continuity of care.
• Stay with the client for the first 15 min of the transfusion: Most transfusion reactions occur during the first 15 minutes. Close observation allows for immediate intervention if the client develops fever, hypotension, or other adverse effects.

• Start an IV bolus of lactated Ringer's solution: Lactated Ringer’s contains calcium which can cause clotting in the transfusion line. Using LR can lead to hemolysis or transfusion complications. Only 0.9% sodium chloride should be used for flushing or running alongside blood transfusions.