The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Choice A rationale:

Fresh frozen plasma (FFP) is a component of blood used to replace clotting factors and is typically indicated for specific medical conditions like bleeding disorders or massive transfusions. In this case, the client requires red blood cells due to significant blood loss, so FFP alone is not the appropriate choice.

Choice B rationale:

Initiating an immediate blood transfusion without the client's consent is not ethically appropriate, especially considering the client's religious beliefs as a Jehovah's Witness. Respecting the client's autonomy and religious convictions is important.

Choice C rationale:

Asking the client to decide about the blood transfusion is the correct course of action. Since the client is able to respond to questions appropriately, they should be informed about their condition, the need for a blood transfusion, and the potential risks and benefits. This respects the client's autonomy while ensuring they have the necessary information to make an informed decision.

Choice D rationale:

Notifying the client's family immediately is not the best initial action. While involving the family is important, the client's own decision about the blood transfusion should take precedence, especially when they are conscious and able to make decisions for themselves.

Choice A rationale:

Cleaning the wound by scrubbing the site with gauze is not an appropriate intervention for a stage 3 pressure ulcer. Scrubbing can damage the fragile tissue, increase the risk of infection, and delay wound healing. Gentle cleaning with a mild solution and avoiding trauma to the wound bed are recommended.

Choice B rationale:

Massaging reddened areas with dressing changes is contraindicated for pressure ulcers, especially stage 3 ulcers. Massaging can cause further damage to the tissues and disrupt the healing process. Dressing changes should focus on maintaining a clean and moist environment to promote healing.

Choice C rationale:

(Correct Choice) Repositioning the client at least every 2 hours is a crucial intervention to prevent further pressure ulcers and facilitate wound healing. Regular repositioning helps relieve pressure on specific areas and improves blood circulation, reducing the risk of tissue breakdown and the development of new ulcers.

Choice D rationale:

Applying a heat lamp twice a day is not recommended for stage 3 pressure ulcers. Heat can increase blood flow to the area, potentially exacerbating inflammation and delaying healing. Pressure ulcers require a clean and moist environment for optimal healing.