A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

Rationale:

A. Boiled eggs: While eggs contain some iron, the type is nonheme, and their consumption alone does not significantly enhance absorption. Eggs lack the vitamin C necessary to improve nonheme iron absorption from plant-based foods.

B. Cheddar cheese: Cheese contains minimal iron and is low in vitamin C. It does not aid in the absorption of nonheme iron and may actually inhibit iron absorption when consumed with iron-rich plant foods due to its high calcium content.

C. Mixed nuts: Nuts provide some nonheme iron, but they do not contain vitamin C to enhance absorption. Consuming nuts alone will not improve bioavailability of iron in a vegetarian diet.

D. Orange slices: Vitamin C in oranges significantly enhances the absorption of nonheme iron from plant-based foods by converting it into a more absorbable form. Including vitamin C-rich foods like oranges with meals helps increase iron uptake, which is particularly important for clients following vegetarian diets.

Rationale:

A. Insert a large-bore IV catheter: A large-bore (18–20 gauge) IV catheter is required to allow rapid infusion of blood products if needed, minimizing hemolysis and ensuring adequate flow. This is critical for the safety and effectiveness of the transfusion, especially in clients who may be hemodynamically unstable.

B. Witness the client signing a consent for transfusion: Obtaining informed consent ensures the client understands the risks, benefits, and alternatives to the blood transfusion. Witnessing the signature is a legal and ethical requirement to confirm that the client has voluntarily agreed to the procedure.

C. Have a second nurse confirm the information on the blood label: Verification by a second nurse prevents administration errors, such as giving the wrong blood type or unit. This double-check process is essential for patient safety and is standard protocol before starting a transfusion.

D. Flush the transfusion tubing with dextrose 5 in water: Blood products should not be administered through tubing flushed with dextrose solutions because dextrose can cause red blood cell hemolysis. Normal saline is the only appropriate solution for priming and flushing blood administration tubing.

E. Explain to the client that transfusion reactions are not serious: Transfusion reactions can be life-threatening, including hemolytic, allergic, or febrile reactions. Minimizing the seriousness of these risks is inappropriate; the client should be informed about potential complications and instructed to report any symptoms immediately.