A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?

A. Infuse the unit of blood to the client over 6 hr: Blood transfusions should be completed within 4 hours to reduce the risk of bacterial growth and hemolysis. Prolonged infusion times increase the likelihood of complications such as infection or reduced efficacy of the transfused blood.

B. Prime the blood administration IV tubing with lactated Ringer’s: Blood products should only be primed and infused with normal saline (0.9% sodium chloride) to prevent hemolysis and clot formation. Lactated Ringer’s contains calcium, which can cause clotting in the blood product, increasing the risk of complications.

C. Check the first set of vital signs 30 min after the blood infusion is started: The nurse should check the client’s vital signs before initiating the transfusion, then again within the first 15 minutes. The highest risk of transfusion reactions occurs within this period, requiring close monitoring for signs such as fever, chills, or hypotension.

D. Document the donation number of the unit of blood on the client’s electronic medical record: Accurate documentation of the blood unit’s donation number ensures traceability and accountability. This information is essential for tracking in case of transfusion reactions or recalls and is a standard safety practice in blood transfusion protocols.

• Wound appearance: The client's wound is consistent in size (3 cm x 4 cm) but the purulent drainage may indicate ongoing infection. However, the key aspect is that the client has a scheduled appointment with a wound care specialist, which suggests that there is a plan in place for managing the wound, indicating that the situation is being monitored and potentially improving with treatment.
• Blood glucose: The blood glucose level decreased from 250 mg/dL two weeks ago to 140 mg/dL today. While still elevated, this reduction indicates better glycemic control, which is essential for overall health and particularly important in the context of healing and managing diabetes.

• WBC: The WBC count increased from 9,500/mm³ to 11,200/mm³. This increase could indicate an ongoing infection or inflammatory process, suggesting that the client's condition is not improving in this regard.
• Urinary frequency: The information provided does not detail any changes in urinary frequency, and given the initial presentation of increased thirst and urination, ongoing monitoring is essential. Without additional context, this does not indicate improvement.
• Temperature: The temperature increased from 38.3°C (100.9°F) to 39.0°C (102.2°F), indicating a worsening state that may suggest infection or systemic response rather than improvement.
• Blood pressure: The blood pressure dropped from 98/74 mm Hg to 90/68 mm Hg, which is concerning and indicates potential hypotension, possibly due to infection or other factors affecting the client’s status.
• Heart rate: The heart rate increased from 104/min to 106/min, suggesting that the client may be experiencing stress, pain, or infection, indicating that their condition may not be improving.