A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.

B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.

C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.

D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.

E. A single blood administration set should not be used for more than 4 hours total due to the risk of bacterial growth. More importantly, running 2 units over a single 4 hour window would mean infusing the blood far too quickly for an older adult, drastically increasing their risk of volume overload. Each unit should be scheduled separately with a careful assessment in between.

Rationale:
A. Having no vesicles prevents the spread of transmission: HSV-2 can be transmitted even when no visible lesions are present through asymptomatic viral shedding. The client should use barrier protection, such as condoms, during all sexual activity to reduce transmission.

B. Antibiotics are the primary treatment for this infection: HSV-2 is a viral infection, and antibiotics are ineffective against viruses. The mainstay of treatment involves antiviral medications such as acyclovir, valacyclovir, or famciclovir.

C. It is a latent infection that may reactivate periodically: HSV-2 remains dormant in nerve ganglia after the initial infection and can reactivate intermittently, leading to recurrent outbreaks triggered by stress, illness, or immunosuppression.

D. It is recommended any partners receive a vaccine to prevent this infection: There is currently no vaccine available to prevent HSV-2 infection. Prevention relies on consistent condom use, abstaining during outbreaks, and open communication with sexual partners about infection status.