A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss.
The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

Choice A rationale
Monitoring for changes in the color of urine to maroon or red is not typically associated with peptic ulcers. This could be a sign of other conditions such as urinary tract infections, kidney stones, or certain medications.
Choice B rationale
Unintentional weight gain is not a common symptom of peptic ulcers. In fact, some people with peptic ulcers may experience weight loss due to discomfort while eating or a decrease in appetite.
Choice C rationale

The appearance of ecchymosis (bruising) on the sides of the abdomen or pelvic areas is not a typical symptom or concern with peptic ulcers. This could be a sign of trauma, certain medications, or other medical conditions.
Choice D rationale
One of the symptoms of a peptic ulcer can be changes in the color of the stool, particularly if it becomes dark or black. This can be a sign of bleeding in the gastrointestinal tract, which can occur with peptic ulcers. Therefore, patients should be advised to monitor for this symptom and seek medical attention if it occurs.

Choice A rationale
Providing information is a communication technique where the nurse gives the patient factual and relevant information. In this scenario, the nurse is not providing information but rather seeking to understand the patient’s feelings.
Choice B rationale
Summarizing is a communication technique where the nurse reviews the main points of the conversation to ensure understanding. In this scenario, the nurse is not summarizing the conversation but rather seeking to understand the patient’s feelings.

Choice C rationale
Clarification is a communication technique where the nurse seeks to understand the patient’s message by asking for more information or for elaboration on a point. In this scenario, the nurse is using clarification by restating the patient’s concern in a different way to confirm their understanding.
Choice D rationale
Confrontation is a communication technique where the nurse addresses observed discrepancies or conflicts in the patient’s behavior or communication. In this scenario, the nurse is not confronting the patient but rather seeking to understand their feelings.