A nurse is assisting in the care of a client in a mental health facility. During group therapy, the client stands up and starts pacing with their fists clenched. Which of the following actions should the nurse take first?

Rationale:

• Document the blood product transfusion in the client’s medical record: It is essential to record the transfusion, including time started and ended, vital signs, and any reactions. Documentation ensures traceability, supports patient safety, and meets regulatory and institutional requirements.

• Monitor the client for the first 15 min of the transfusion: The first 15 minutes are the most critical for detecting transfusion reactions, such as fever, chills, rash, or anaphylaxis. Continuous monitoring during this window allows for prompt intervention if adverse symptoms occur.

• Assist with obtaining the first unit of packed RBCs from the blood bank: RNs or authorized personnel can retrieve blood from the blood bank. Proper handling and timely transport of the blood ensure viability and reduce the risk of hemolysis or temperature-related damage.

• Assist with titrating the rate of infusion to maintain the client’s blood pressure at 90/60 mm Hg or above: Titrating transfusion rates based solely on BP is not within nursing protocol unless specifically ordered. Blood products must be infused according to prescription typically over 2 to 4 hours per unit unless a reaction or complication occurs.

• Start an IV bolus of lactated Ringer’s solution: The provider specifically prescribed a 0.9% sodium chloride bolus. Lactated Ringer’s is contraindicated during transfusions because it contains calcium, which can cause clotting when mixed with blood products.

• Discard the blood bag in the client’s trash can after the transfusion: Blood bags must be disposed of in biohazard containers to comply with infection control policies. Discarding medical waste in general trash violates safety protocols and increases contamination risk.

Rationale:

A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.

B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.

C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.

D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.