A nurse is caring for a client at a clinic.

Exhibits

Complete the following sentence by using the lists of options. The client is at risk for developing

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due to

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Rationale
1. Stay with the client for the first 15 minutes of the transfusion.

Indicated
This is a standard protocol for blood transfusions. The first 15 minutes of the transfusion are the most critical because acute transfusion reactions (such as allergic reactions, febrile reactions, or hemolysis) are most likely to occur during this time. By staying with the client, the nurse can monitor for any signs of reaction (e.g., fever, chills, shortness of breath, rash) and intervene immediately if necessary.

2. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

Indicated
Given the client’s low blood pressure (hypotension), it is important to monitor and potentially titrate the rate of infusion during the blood transfusion. The nurse should ensure that the blood pressure is maintained at an acceptable level. Blood transfusions can cause fluid shifts and affect hemodynamics, so the nurse may adjust the transfusion rate based on the client's vital signs to maintain adequate blood pressure and avoid complications, such as fluid overload or inadequate tissue perfusion.
3. Obtain the first unit of packed RBCs from the blood bank.

Indicated
The client is being prepared for a blood transfusion, so obtaining the blood product from the blood bank is a necessary step. The nurse must ensure that the correct blood product (two units of packed RBCs) is ordered, cross-matched, and ready for administration. Blood verification is critical to avoid transfusion errors, and this step is essential for the transfusion process.
4. Start an IV bolus of lactated Ringer's solution.
The provider’s prescription specifies a 500 mL bolus of normal saline (0.9% sodium chloride), not lactated Ringer's solution. Normal saline is preferred for blood transfusions because it does not contain calcium, which can bind to the citrate in blood products and cause clotting or other complications. Using the correct IV solution is essential for safety.
5. Document the blood product transfusion in the client's medical record.

Indicated
Proper documentation is essential in nursing practice. The nurse must record key information regarding the blood transfusion, including the type of blood product, the date and time of transfusion, the rate of infusion, and any reactions or complications. Documentation helps ensure continuity of care, and it is required by legal and institutional standards.

A. Nebulized bronchodilators should be administered after airway clearance therapy to open the airways before the therapy.
B. Pancreatic enzymes should be administered with meals and snacks, not on an empty stomach, to aid digestion.
C. Gluten restriction is not typically required for cystic fibrosis unless the child also has celiac disease.
D. Chest percussion and postural drainage should be performed multiple times per day, not just twice.