A nurse is caring for a client who has an indwelling urinary catheter.

The nurse notes that sediment is present in the urine.

Which of the following actions should the nurse take to obtain a sterile urine specimen?

Choice A reason

Setting the IV infusion pump to administer the blood over 6 hours is not the recommended rate for administering packed RBCs. Blood transfusions are typically given more rapidly, usually within 2 to 4 hours. The specific rate may vary depending on the client's condition and the provider's order.

Choice B reason

Administering the blood via a 21-gauge IV needle is not typically related to the administration of the packed RBCs. The appropriate gauge of the IV needle for blood transfusions depends on the client's condition and the type of transfusion. Larger-gauge needles are often used for blood transfusions to allow for a faster flow rate and prevent haemolysis of the blood cells.

Choice C reason

Checking the client's vital signs from the previous shift prior to the initiation of the transfusion is not sufficient for ensuring the client's safety during the blood transfusion. The nurse should assess the client's current vital signs, including temperature, heart rate, blood pressure, and respiratory rate, before initiating the transfusion. Monitoring vital signs is essential during the transfusion to detect any adverse reactions or changes in the client's condition.

Choice D reason

Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion is the correct answer. When preparing to administer a blood transfusion to an adult client with chronic anaemia, the nurse should rush the blood administration tubing with 0.9% sodium chloride (normal saline) prior to the transfusion. This process is called priming the tubing.

Priming the tubing helps remove any residual air from the tubing and ensures that the blood transfusion is administered smoothly without introducing air into the client's bloodstream. Air embolisms can be a serious complication, and priming the tubing with normal saline helps prevent this risk.

The correct answer is choice D. Speak directly to the client. This is because the nurse should establish eye contact and rapport with the client, not the interpreter, and show respect for the client’s culture and autonomy. The nurse should also use simple and clear language, avoid jargon and slang, and speak in short sentences.

Choice A is wrong because using gestures to convey meaning can be confusing or offensive to some cultures. The nurse should avoid relying on nonverbal communication and ask the interpreter for clarification if needed.

Choice B is wrong because pausing in the middle of sentences can disrupt the flow of communication and make it harder for the interpreter to translate accurately. The nurse should pause at the end of each complete thought or sentence to allow the interpreter to relay the information.

Choice C is wrong because speaking slowly when talking to the interpreter can imply that the interpreter is incompetent or unintelligent. The nurse should speak at a normal pace and tone, and allow enough time for the interpreter to translate.