A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.

Exhibits

Which of the following interventions should the nurse implement?

Select all that apply.

Assess peripheral circulation hourly.

Assess the client's mouth every 8 hr.

Use humidification with oxygen therapy. Administer IV fluids.

Raise the knee position on the client's bed.

Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion.

Answer and Explanation

Correct Answer : A,B,C

A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.

B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.

C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.

D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.

E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vasoocclusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.

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Correct Answer is D

Explanation

Proceed with provision of medical care.

A. Contact the facility's ethics committee: This is incorrect because it is not an urgent action and it does not address the client's immediate needs. The ethics committee can be consulted later if there are ethical dilemmas or conflicts regarding the client's care.
B. Obtain consent from the client's employer: This is incorrect because it is not a valid source of consent. The employer has no legal or ethical authority to make decisions for the client, unless they are also a designated surrogate or proxy.
C. Limit care to comfort measures: This is incorrect because it does not meet the standard of care for an emergency situation. The nurse has a duty to provide life-saving interventions for a client who is unconscious and requires emergency medical procedures, unless there is evidence of a valid advance directive that states otherwise.
D. Proceed with provision of medical care: This is correct because it follows the principle of implied consent, which assumes that a reasonable person would consent to emergency treatment if they were able to do so. The nurse should document the circumstances and continue to search for family members or other sources of consent.

A. Hang the transfusion with dextrose 5% in 0.9% sodium chloride. B. Infuse the transfusion over 5 hr. C. Use a 20-gauge IV catheter to transfuse the blood. D. Monitor vital signs every hour throughout the transfusion.

Correct Answer is D

Explanation

Choice A rationale:

Hanging the transfusion with dextrose 5% in 0.9% sodium chloride is incorrect. Packed red blood cells (PRBCs) are transfused with normal saline (0.9% sodium chloride) and not with dextrose-containing solutions. Using dextrose can cause the red blood cells to hemolyze.

Choice B rationale:

Infusing the transfusion over 5 hours is incorrect. PRBC transfusions are typically administered over 2-4 hours, not 5 hours. Infusing the blood too slowly may cause the patient discomfort and may also increase the risk of bacterial growth in the blood product.

Choice C rationale:

Using a 20-gauge IV catheter to transfuse the blood is incorrect. While a 20-gauge IV catheter is suitable for most blood transfusions, it may not be appropriate for older adults or patients with fragile veins. A smaller gauge, such as 22 or 24, might be more suitable to prevent phlebitis and ensure a steady flow without damaging the blood cells.

Choice D rationale:

Monitoring vital signs every hour throughout the transfusion is the correct action. During a blood transfusion, it's crucial to monitor the patient's vital signs frequently to detect any adverse reactions promptly. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, should be assessed before the transfusion, 15 minutes after starting the transfusion, and then hourly thereafter. This vigilant monitoring helps in identifying potential transfusion reactions, such as fever, chills, or hypotension, allowing for immediate intervention if needed.

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A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.

Exhibits

Which of the following interventions should the nurse implement?

Select all that apply.