A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider?

A. Educate a client about the purpose of a sputum specimen: Client education requires nursing knowledge and judgment to explain procedures, answer questions, and evaluate understanding. This cannot be delegated to assistive personnel.

B. Perform irrigation of an indwelling urinary catheter: Catheter irrigation is a sterile invasive procedure that requires nursing skill to prevent infection and complications. It falls outside the scope of assistive personnel.

C. Administer liquid aspirin to a client who is crying: Medication administration involves assessment, calculation, and monitoring for adverse effects, which are responsibilities of a licensed nurse. Assistive personnel cannot administer medications.

D. Provide a bed bath for a client who requires isolation precautions: Assisting with hygiene is within the scope of assistive personnel. They can safely provide a bed bath while following isolation protocols under the supervision of the nurse.

Rationale:

• 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.