A nurse is caring for a client who has a placenta previa.

Which of the following findings should the nurse expect?

Choice A reason:

Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.

Choice B reason:

Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag

Choice C reason:

Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.

Choice D reason

Infuse 500 ml lactated Ringer's IV. This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.

The correct answer is: B

Choice A reason: A social worker may assist clients in many ways, including finding legal representation. However, this statement does not address the client’s concern about the cost of legal representation for advance directives. It’s important to note that while social workers can provide support, they do not eliminate the need for legal representation if the client chooses to seek it.

Choice B reason: This is the correct statement because advance directives do not require legal representation to be valid. They become legally binding when signed in front of the required witnesses. This option directly addresses the client’s concern about affording legal representation by informing them that it is not necessary for the creation of advance directives.

Choice C reason: While medical care can be initiated without advance directives, this statement does not address the client’s concern about the cost of creating advance directives. It also implies that medical care is contingent on the completion of legal documents, which is not accurate.

Choice D reason: Verbal agreements are not as legally binding as written advance directives and could lead to misunderstandings or disputes later on. It is important for the client to have a clear and documented advance directive, which does not necessarily require legal review to be valid.