A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first?

A. Prospective audit: A prospective audit evaluates care before it is provided, focusing on planned interventions rather than outcomes after discharge. It is not used to assess post-care quality.

B. Outcome audit: Outcome audits measure the results of care, such as client recovery, complication rates, or satisfaction, after interventions have been completed. This type of audit is appropriate for gathering information about quality of care following discharge.

C. Structure audit: Structure audits assess the resources, staffing, and organizational infrastructure used to deliver care. They do not measure client outcomes or post-discharge quality.

D. Concurrent audit: Concurrent audits evaluate care while it is being provided, allowing immediate feedback and corrections. They are performed during hospitalization, not after discharge.

Rationale for indicated actions:

• Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: The nurse should follow the ordered transfusion rate and not titrate it based on blood pressure. The priority is to transfuse the blood safely and at the prescribed rate, while monitoring the client's response. Blood pressure will improve as the blood volume is restored.
• Obtain the first unit of packed RBCs from the blood bank: This is necessary to correct the client’s anemia (Hgb 9.1 g/dL, Hct 27%) and address the suspected acute blood loss indicated by positive hemoccult stool and hemodynamic changes.
• Document the blood product transfusion in the client's medical record: Accurate documentation ensures legal compliance, tracks the administration, and records the client’s response, including any adverse events, supporting continuity of care.
• Stay with the client for the first 15 min of the transfusion: Most transfusion reactions occur during the first 15 minutes. Close observation allows for immediate intervention if the client develops fever, hypotension, or other adverse effects.

• Start an IV bolus of lactated Ringer's solution: Lactated Ringer’s contains calcium which can cause clotting in the transfusion line. Using LR can lead to hemolysis or transfusion complications. Only 0.9% sodium chloride should be used for flushing or running alongside blood transfusions.