A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

Initiate transmission-based precautions.

Rationale:

1. B- Encouraging oral fluids is an important intervention for a child who has a fever, as it helps prevent dehydration and electrolyte imbalance. However, it is not the priority intervention, as it does not address the risk of infection transmission to other clients or staff.
2. A - Applying topical calamine lotion may help soothe the itching and discomfort caused by the vesicles, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
3. C - Administering acetaminophen as an antipyretic may help reduce the fever and provide symptomatic relief for the child, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
4. D - Initiating transmission-based precautions is the priority intervention, as it protects other clients and staff from exposure to the infectious agent that causes the vesicles and fever. The nurse should wear gloves, gown, mask, and eye protection when caring for the child, and place them in a private room or cohort them with other clients who have similar symptoms.

Maintain sterile objects within the line of vision.

• A. Hold hands folded below the waist after donning sterile gloves. This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.
• B. Pick up and pour solutions with the palm of the hand covering bottle labels. This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.
• C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.
• D. Maintain sterile objects within the line of vision. This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.