The nurse is assisting with the care of a client who is receiving a unit of packed RBCs.

Exhibits

Complete the following sentence by using the lists of options. Exhibit 1

The client has manifestations of an

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as evidenced by the client's

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A: The neurological findings were already noted in the nurse's initial assessment, and the client's orientation and movement of extremities are within the expected range postoperatively.
Therefore, it does not require immediate reporting.
B: While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to be reported to the provider unless drainage continues or increases over time.
C: Monitoring urinary output is essential, especially in a postoperative client, as it helps assess renal function and hydration status. Any significant changes in urinary output should be reported to the provider promptly.
D: The client's reported pain level of 6 on a scale of 0 to 10 indicates moderate pain, and the provider should be informed to address the pain and consider adjustments to the pain management plan.

E.Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide.

F.Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.

A. "Tell me what the afterlife means to you." Correct. This response demonstrates active listening and encourages the client to share their beliefs and feelings about the afterlife, providing the client with an opportunity for spiritual expression and understanding.
B. "You should discuss the afterlife with your priest." While discussing spiritual matters with a religious leader can be valuable, this response does not directly address the client's request for
the nurse to discuss the afterlife with them.
C. "Keep praying. A miracle could happen." This response may not fully address the client's need to discuss their beliefs about the afterlife. It focuses on hope but does not actively engage in the client's spiritual conversation.
D. "Maybe your condition will lead you closer to God." While offering comfort, this response may not meet the client's request to discuss the afterlife directly.