A nurse is planning care for an older adult client who has dementia.

Which of the following interventions should the nurse include in the plan of care? (Select all that apply.).

Choice A reason:

Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.

Choice B reason:

Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag

Choice C reason:

Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.

Choice D reason

Infuse 500 ml lactated Ringer's IV. This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.

Answer is… C and F indicate improvement.

A The client has gained 1.8 kg (4 lb). BMI is 18.9. This is not an improvement because the client’s BMI is still below the normal range of 18.5 to 24.9 The client may have malnutrition or other health problems that affect their weight.

B The clients adult child prepares two meals per day for the client. This is not an improvement because it shows that the client still depends on others for their basic needs and may have difficulty with self-care.

C The clients clothing is clean and appropriate for the weather. This is an improvement because it shows that the client has good hygiene and can dress themselves appropriately.

D The client receives three baths per week from a home care aide. This is not an improvement because it shows that the client still needs assistance with bathing and may have limited mobility or pain.

E The client reports frequent toothaches and lack of dental care. This is not an improvement because it shows that the client has poor oral health and may have infections or other complications.

F The client makes eye contact and smiles when speaking. This is an improvement because it shows that the client has positive mood and social interaction.

: https://www.hopkinsmedicine.org/health/conditions-and-diseases/distal-radius-fracture- wrist-fracture : https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.