A nurse is caring for a client in the outpatient mental health clinic

exhibits

Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again
Nurses' Notes
Today

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation

Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

Indicated:

Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mmHg: - The client is hypotensive (76/45 mmHg), likely due to acute blood loss anemia from a gastrointestinal (GI) bleed. Adjusting the transfusion rate helps stabilize BP while preventing volume overload.

Stay with the client for the first 15 minutes of the transfusion: The highest risk of a transfusion reaction (e.g., hemolysis, anaphylaxis, febrile reaction) occurs within the first 15 minutes, so the nurse must remain with the client for close monitoring.

Obtain the first unit of packed RBCs from the blood bank: The client’s condition (hypotension, tachycardia, history of melena) suggests GI bleeding and significant blood loss. RBC transfusion is required to restore oxygen-carrying capacity and improve perfusion.

Document the blood product transfusion in the client’s medical records: Proper documentation includes blood product type, volume infused, time started and completed, client response, and any adverse reactions. This ensures compliance with safety protocols.

Not Indicated:

Start an IV bolus of lactated Ringer’s solution: Lactated Ringer’s (LR) is incompatible with blood products because it contains calcium, which can cause clotting in the IV line. Normal saline (0.9% NaCl) should be used instead.

A. Incorrect. Initiating seclusion protocol should only be done in situations where the safety of the client or others is at risk and after appropriate assessment and intervention.

B. Correct. Acknowledging the client's emotions and showing empathy can help defuse the situation and promote effective communication.

C. Incorrect. Using personal protective equipment (face shield with mask) is not necessary when interacting with an agitated client unless there is a specific infection control concern.

D. Incorrect. Engaging the panic alarm is not necessary in this situation, as it may escalate the client's agitation.