A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.

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. Removing an NG tube: Removing a nasogastric tube is a task that can be safely delegated to a licensed practical nurse (LPN) under appropriate supervision, as it is considered a stable, routine procedure that does not require complex assessment.

B. Administering a subcutaneous insulin injection: LPNs are trained and authorized to administer subcutaneous injections, including insulin, as long as the client's condition is stable and the dose is clearly prescribed.

C. Providing discharge teaching about home IV medication therapy: Discharge education involving IV therapy requires comprehensive teaching, clinical judgment, and evaluation of understanding, which falls within the scope of practice of a registered nurse (RN).

D. Collecting a sputum culture: Collecting a sputum specimen is a basic nursing task that can be performed by an LPN or even by trained assistive personnel, depending on facility policy. It does not require the expertise of an RN.