A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy.

Exhibits

Complete the following sentence by using the lists of options.

The client is at the highest risk for developing hypocalcemia evidenced by the

- A. Correct. The nurse should turn off the CPM machine during mealtime to allow the client to eat comfortably and prevent aspiration.

- B. Incorrect. The nurse should maintain the client's affected hip in a neutral position to prevent dislocation of the prosthesis and promote healing.

- C. Incorrect. The nurse should not instruct the client how to adjust the CPM settings for comfort, as this could interfere with the prescribed range of motion and speed of the device. The nurse should notify the provider if the client reports discomfort or pain.

- D. Incorrect. The nurse should not store the CPM machine under the client's bed when not in use, as this could pose a safety hazard and damage the device. The nurse should place the CPM machine on a stable surface away from the bed.

Choice A rationale:

Hanging the transfusion with dextrose 5% in 0.9% sodium chloride is incorrect. Packed red blood cells (PRBCs) are transfused with normal saline (0.9% sodium chloride) and not with dextrose-containing solutions. Using dextrose can cause the red blood cells to hemolyze.

Choice B rationale:

Infusing the transfusion over 5 hours is incorrect. PRBC transfusions are typically administered over 2-4 hours, not 5 hours. Infusing the blood too slowly may cause the patient discomfort and may also increase the risk of bacterial growth in the blood product.

Choice C rationale:

Using a 20-gauge IV catheter to transfuse the blood is incorrect. While a 20-gauge IV catheter is suitable for most blood transfusions, it may not be appropriate for older adults or patients with fragile veins. A smaller gauge, such as 22 or 24, might be more suitable to prevent phlebitis and ensure a steady flow without damaging the blood cells.

Choice D rationale:

Monitoring vital signs every hour throughout the transfusion is the correct action. During a blood transfusion, it's crucial to monitor the patient's vital signs frequently to detect any adverse reactions promptly. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, should be assessed before the transfusion, 15 minutes after starting the transfusion, and then hourly thereafter. This vigilant monitoring helps in identifying potential transfusion reactions, such as fever, chills, or hypotension, allowing for immediate intervention if needed.