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 it is true that an increased weight in the abdomen can lead to discomfort when lying down, simply having extra pillows in bed may not be sufficient to address the issue. Ascites, or the accumulation of fluid in the peritoneal cavity, can cause significant discomfort and even

pain. It can also lead to respiratory issues as the fluid puts pressure on the diaphragm, making breathing difficult. Therefore, while extra pillows may help to some extent by allowing the patient to find a more comfortable position, they are not a comprehensive solution.
Choice B rationale
Advising the patient not to wear undergarments because they will not fit due to the increased weight in the abdomen is not a medically sound advice. While it is true that ascites can cause distension of the abdomen, the focus should be on treating the underlying condition and managing the symptoms, rather than on the fit of the patient’s clothing. Moreover, the choice of clothing is a personal decision and may have psychological implications for the patient.
Choice C rationale
The statement that the increased weight in the abdomen means that the patient can no longer exercise due to the strain on the heart is not entirely accurate. While it is true that ascites can put additional strain on the heart and other organs, it does not necessarily mean that all forms of exercise are contraindicated. In fact, gentle forms of exercise may be beneficial for overall health and well-being. However, any exercise regimen should be discussed with and approved by a healthcare provider.
Choice D rationale
This is the correct choice. Due to the increased abdominal weight from ascites, the patient’s balance might indeed be affected, increasing the risk of falls. Therefore, advising the patient to take their time with walking is a valid precaution. Fall prevention is a key aspect of care for patients with ascites due to end-stage liver disease.

Choice A rationale
A stool guaiac test is a simple check to find blood in your stool. It involves smearing a tiny amount of your stool on a special card, which is then tested for hidden blood. This test helps detect problems like bleeding ulcers or colon cancer in an early stage when they might not show other symptoms. The stool guaiac test looks for hidden (occult) blood in a stool sample. It can find blood even if you cannot see it yourself. It is a common type of fecal occult blood test (FOBT). Guaiac is a substance from a plant that is used to coat the FOBT test cards to make them able to detect blood.
Choice B rationale
Steatorrhea refers to the presence of excess fat in the stool. While this can be a symptom of various digestive disorders, it is not what a stool guaiac test is designed to detect. The primary purpose of a stool guaiac test is to identify hidden blood in the stool, which can be an indicator of conditions such as gastrointestinal bleeding or colon cancer.
Choice C rationale
While bacteria can be present in the stool and certain tests are designed to detect them, a stool guaiac test is not one of these. The stool guaiac test is specifically designed to detect the presence of hidden blood in the stool. The presence of blood can indicate a variety of conditions, including gastrointestinal bleeding or colon cancer.
Choice D rationale
Yeast can be present in the stool, and certain tests can detect it. However, a stool guaiac test is not designed to detect yeast. The primary purpose of a stool guaiac test is to identify hidden

blood in the stool, which can be an indicator of conditions such as gastrointestinal bleeding or colon cancer.