A nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data from the client.

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should identify that

dropdown

and

dropdown

indicate manifestations of borderline personality disorder.

A. Place a pulse oximeter on the client's finger. While assessing oxygen saturation is important, it is not the priority in this situation. The client is cyanotic with a respiratory rate of 8/min and shallow respirations, indicating severe respiratory compromise. Immediate intervention is needed before assessing oxygen saturation.
B. Administer oxygen to the client. Providing oxygen is appropriate, but it will not be effective if the client's airway is obstructed or if their respirations are inadequate. Oxygen delivery is only useful when there is a patent airway and effective ventilation.
C. Check the client's pulse rate. Assessing circulation is important, but the priority in this situation is ensuring an open airway to allow for adequate oxygenation. The client's respiratory status suggests that they may not be effectively exchanging oxygen, which must be addressed immediately.
D. Establish a patent airway for the client. The priority action is to ensure a patent airway, as compromised respirations can lead to respiratory failure and cardiac arrest. Airway management, such as repositioning the head, using airway adjuncts, or preparing for assisted ventilation, takes precedence over other interventions to ensure oxygen delivery.

A. Obtain a large-bore IV catheter. A large-bore IV catheter (18-gauge or larger) is necessary for blood transfusion to allow for rapid administration and reduce the risk of hemolysis. The provider has already prescribed this intervention.
B. Explain to the client that transfusion reactions are not serious. This statement is inaccurate and misleading. While many transfusion reactions are mild, some can be life-threatening, such as hemolytic reactions or anaphylaxis. The nurse should educate the client about signs and symptoms of a transfusion reaction and instruct them to report any discomfort or unusual sensations immediately.
C. Ensure two nurses confirm the information on the blood label. Before administering blood, two nurses must verify the blood product against the client's identification band, medical record, and blood bank documentation to prevent transfusion errors.
D. Ensure the transfusion tubing is flushed with dextrose 5% in water. Blood products should only be administered with normal saline (0.9% sodium chloride) because dextrose-containing solutions can cause red blood cell hemolysis. The nurse should ensure the IV tubing is primed with normal saline before starting the transfusion.
E. Witness the client signing consent for transfusion. Informed consent is required before administering a blood transfusion. While obtaining consent is the provider’s responsibility, the nurse can witness the signing and ensure that the client understands the procedure.