A nurse is assessing a client who is experiencing a hypertensive crisis. Which of the following manifestations should the nurse expect?

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.

Rationale:

A. "I recommend that you take this medication as prescribed.": This response dismisses the client’s concern and does not address the possibility of a medication error. It can also undermine trust and ignores the need for verification before administration.

B. "I will call the pharmacist now to check on this medication.": This is the most appropriate response because it prioritizes client safety by verifying the medication before administration. It also acknowledges the client’s concern and involves a qualified resource for confirmation.

C. "Did the doctor discuss with you that there was a change in this medication?": While this could provide insight into changes in therapy, it delays immediate verification and does not address the need to confirm the medication’s accuracy before giving it.

D. "Do you know why this medication is being prescribed for you?": This may promote client education, but it does not address the immediate safety concern or the need to verify the medication before administration.