A nurse is unfamiliar with a medication they are preparing to administer to a client. Prior to administering the medication, the nurse should refer to which of the following resources?

• Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
• Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
• Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
• Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.

Not Indicated:

• Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
• Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.

A. Acute onset of confusion. Dementia is a progressive, chronic condition that develops gradually over time. An acute onset of confusion is more characteristic of delirium, which is a sudden, reversible condition often caused by infections, metabolic imbalances, or medications.
B. Illusions. While individuals with dementia may experience visual misperceptions, true illusions—misinterpretations of real external stimuli—are more commonly associated with delirium or psychiatric disorders. Dementia more often leads to problems with recognition (agnosia) rather than distorted perception.
C. Memory loss that disrupts ADLs. Dementia is characterized by progressive cognitive decline, including memory impairment severe enough to interfere with daily activities such as managing finances, preparing meals, or personal hygiene. As the disease progresses, individuals may struggle with problem-solving, language, and recognizing familiar people or places.
D. Catatonia. Catatonia is a state of motor dysfunction, often seen in severe psychiatric disorders like schizophrenia. While individuals with advanced dementia may become withdrawn or exhibit reduced movement, true catatonia, which involves stupor or repetitive movements, is not a hallmark of dementia.