A nurse is monitoring a client who is receiving a unit of packed red blood cells (RBCs) following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

Choice A reason: Client report of a headache is not the nurse's priority to report to the provider. A headache is a common and mild side effect of vancomycin, which is an antibiotic used to treat serious infections. A headache may be caused by dehydration, stress, or other factors, and can be relieved by drinking fluids, resting, or taking analgesics.

Choice B reason: Audible inspiratory stridor is the nurse's priority to report to the provider. Stridor is a high-pitched, wheezing sound that occurs when breathing in, and indicates a narrowing or obstruction of the airway. Stridor may be a sign of a severe allergic reaction, or anaphylaxis, to vancomycin, which can be life-threatening. Anaphylaxis can also cause swelling of the face, lips, tongue, or throat, difficulty breathing, low blood pressure, and shock. The nurse should stop the infusion, administer epinephrine, and monitor the client's vital signs.

Choice C reason: Client report of tinnitus is not the nurse's priority to report to the provider. Tinnitus is a ringing or buzzing sound in the ears, and may be a rare and serious side effect of vancomycin. Tinnitus may indicate damage to the inner ear, or ototoxicity, which can lead to hearing loss. The nurse should check the client's hearing and report any changes to the provider. The provider may adjust the dose or frequency of vancomycin, or switch to another antibiotic.

Choice D reason: Localized redness at the catheter insertion site is not the nurse's priority to report to the provider. Redness at the catheter insertion site may indicate irritation, inflammation, or infection of the skin or vein, and may be caused by the needle, the catheter, or the medication. The nurse should inspect the site, clean it with antiseptic, and apply a sterile dressing. The nurse should also monitor the site for signs of phlebitis, such as pain, swelling, warmth, or pus. The nurse may need to change the catheter or the infusion site if the redness persists or worsens.

Choice A reason: Using an electric razor while on warfarin is the correct instruction. Warfarin is an anticoagulant that inhibits the formation of blood clots and prolongs the bleeding time. Using an electric razor can reduce the risk of cuts and bleeding while shaving. The client should avoid using sharp objects or instruments that can cause injury or trauma.

Choice B reason: Doubling the dose of warfarin if a dose is missed is not the correct instruction. This is a dangerous and potentially fatal advice, as it can cause overdose and severe bleeding. The client should take the missed dose as soon as possible, unless it is close to the next scheduled dose, in which case the client should skip the missed dose and resume the regular dosing schedule. The client should never take extra doses or change the dose without consulting the provider.

Choice C reason: Mild nosebleeds being common during initial treatment is not the correct instruction. This is a false and misleading statement, as nosebleeds are not a normal or expected side effect of warfarin therapy. Nosebleeds can indicate bleeding problems or complications, such as thrombocytopenia, which is a low platelet count. The client should report any nosebleeds or other signs of bleeding, such as bruising, petechiae, hematuria, or melena, to the provider immediately.

Choice D reason: Increasing fiber intake to reduce the adverse effect of constipation is not the correct instruction. This is an irrelevant and unnecessary recommendation, as constipation is not a common or serious adverse effect of warfarin therapy. Constipation can be caused by many factors, such as diet, hydration, activity, or medication. The client should maintain a balanced and consistent diet, drink plenty of fluids, and exercise regularly to prevent constipation. The client should also avoid foods that are high in vitamin K, such as green leafy vegetables, as they can interfere with the effect of warfarin.