A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse’s priority action?

Choice A rationale

While a 25-year-old planning to lose 20 pounds after childbirth may have increased nutritional needs, they would not typically be considered at higher risk for malnutrition unless there were other factors such as inadequate diet or certain health conditions.
Choice B rationale
A 65-year-old who recently underwent hernia surgery might have temporary changes in diet or appetite related to the surgery, but would not typically be at high risk for malnutrition unless there were other ongoing issues such as poor diet, difficulty eating, or a chronic health condition.
Choice C rationale
A 70-year-old who has been fasting since midnight in preparation for a colonoscopy would not typically be at risk for malnutrition from this short-term fast. However, if they had ongoing issues with diet, appetite, or a chronic health condition, they could potentially be at risk.
Choice D rationale
A 55-year-old who has been consuming alcohol for 35 years is at higher risk for malnutrition. Alcohol can interfere with the body’s ability to absorb and use nutrients, and individuals with long-term heavy alcohol use may also have other lifestyle factors that increase their risk for malnutrition.

Choice A rationale

Anemia due to excessive blood loss during surgery can lead to a variety of symptoms. One of the most common symptoms is fatigue. This is because anemia results in a decrease in the amount of oxygen that can be delivered to the body’s tissues, leading to a lack of energy and feelings of exhaustion. Therefore, a nurse should expect to find fatigue in a postoperative client who has anemia due to excessive blood loss during surgery.
Choice B rationale
Bradycardia, or a slower than normal heart rate, is not typically associated with anemia. Instead, anemia can actually lead to tachycardia, or a faster than normal heart rate, as the body tries to compensate for the decreased oxygen carrying capacity of the blood.
Choice C rationale
Hypertension, or high blood pressure, is not a typical finding in patients with anemia. In fact, in severe cases, anemia can lead to hypotension, or low blood pressure, due to a decrease in the blood’s ability to carry oxygen.
Choice D rationale
Diarrhea is not a common symptom of anemia. Anemia due to excessive blood loss during surgery is more likely to result in symptoms related to a lack of oxygen in the body’s tissues, such as fatigue, weakness, and shortness of breath.