A nurse is reinforcing teaching with an older adult client about home safety. Which of the following client statements indicates an understanding of the teaching?

Rationale:

• Document the blood product transfusion in the client’s medical record: It is essential to record the transfusion, including time started and ended, vital signs, and any reactions. Documentation ensures traceability, supports patient safety, and meets regulatory and institutional requirements.

• Monitor the client for the first 15 min of the transfusion: The first 15 minutes are the most critical for detecting transfusion reactions, such as fever, chills, rash, or anaphylaxis. Continuous monitoring during this window allows for prompt intervention if adverse symptoms occur.

• Assist with obtaining the first unit of packed RBCs from the blood bank: RNs or authorized personnel can retrieve blood from the blood bank. Proper handling and timely transport of the blood ensure viability and reduce the risk of hemolysis or temperature-related damage.

• Assist with titrating the rate of infusion to maintain the client’s blood pressure at 90/60 mm Hg or above: Titrating transfusion rates based solely on BP is not within nursing protocol unless specifically ordered. Blood products must be infused according to prescription typically over 2 to 4 hours per unit unless a reaction or complication occurs.

• Start an IV bolus of lactated Ringer’s solution: The provider specifically prescribed a 0.9% sodium chloride bolus. Lactated Ringer’s is contraindicated during transfusions because it contains calcium, which can cause clotting when mixed with blood products.

• Discard the blood bag in the client’s trash can after the transfusion: Blood bags must be disposed of in biohazard containers to comply with infection control policies. Discarding medical waste in general trash violates safety protocols and increases contamination risk.

Rationale:

A. "Colostrum provides vitamin K which is an essential nutrient for newborns." While vitamin K is essential for clotting, it is not found in sufficient amounts in colostrum. This is why newborns routinely receive a vitamin K injection shortly after birth, rather than relying on breast milk as a source.

B. "Colostrum provides many important antibodies that the newborn lacks." Colostrum is rich in immunoglobulins, especially IgA, which help protect the newborn from pathogens by providing passive immunity. These antibodies line the infant's gastrointestinal tract and offer critical defense during early life.

C. "Colostrum contains iron, which is important for a newborn's brain development." Although breast milk contains iron, colostrum is not a major source of it. Newborns are typically born with adequate iron stores to last several months, and the primary role of colostrum is immune protection, not iron supplementation.

D. "Colostrum contains a natural diuretic that stimulates the newborn to void." While colostrum has a laxative effect that helps the newborn pass meconium, there is no known diuretic component. Its primary importance lies in delivering antibodies and coating the GI tract to reduce infection risk.