A nurse is caring for an older adult client.

exhibits

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says. "Why don't you just leave me? I am of no use.”

This is because continuous enteral feedings through an NG tube can increase the risk of aspiration, which is the inhalation of food or fluids into the lungs. Measuring gastric residual volumes (GRV) can help monitor the tolerance and absorption of the feedings and prevent overfeeding. GRV is the amount of fluid aspirated from the stomach via an enteral tube to check for gastric emptying. The normal range of GRV is less than 200 ml.

Choice B is wrong because advancing the rate of the feeding every 2 hr can lead to overfeeding, abdominal distension, nausea, vomiting and diarrhea.

The rate of the feeding should be adjusted according to the client’s nutritional needs and tolerance.

Choice C is wrong because maintaining the head of the bed at a 20° angle is not enough to prevent aspiration. The head of the bed should be elevated at least 30° to 45° during and for at least one hour after feeding.

Choice D is wrong because flushing the NG tube with 30 mL 0.9% sodium chloride before and after medication is not related to continuous enteral feedings. This is a practice to prevent clogging of the tube and ensure proper delivery of medication. Flushing the tube with water before and after feeding is also recommended to maintain patency and hydration.

Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.

Explanation:.

• Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
• Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
• Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
• Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
• Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.