A nurse is caring for a client in the intensive care unit.

Exhibits

The nurse is reviewing the admission assessment, nurses' notes, vital signs, and laboratory results. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies that the client's and can indicate the development of delirium.

A. The wall suction setting does not directly indicate the functioning of the NG tube.

B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting

that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.

C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.

D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.

A.

A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop

the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.

B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.

C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.

D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.