The nurse is caring for a client.

Which of the following actions should the nurse take? Select all that apply.

A. Prime the infusion tubing with 0.45% sodium chloride: Blood products should never be infused with hypotonic solutions like 0.45% sodium chloride, as this can cause hemolysis. Only 0.9% sodium chloride (normal saline) is safe for priming blood tubing.

B. Infuse the blood over 4 hr: Transfusion for older adults should generally be completed within 2–4 hours per unit to prevent fluid overload while allowing safe administration. Monitoring for signs of transfusion reactions or circulatory overload is critical.

C. Verify with another nurse that the unit of blood is compatible with the client's blood type: Independent verification by two qualified nurses ensures correct blood type and crossmatch, reducing the risk of hemolytic transfusion reactions.

D. Don sterile gloves to prepare the blood administration setup: Sterile gloves are not required for routine blood administration; clean gloves are sufficient to maintain standard precautions.

E. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps identify preexisting conditions such as fluid overload or pulmonary congestion, which is important for older adults at risk for transfusion-associated circulatory overload (TACO).

A. Discuss the client's strengths and weaknesses with the client: Exploring strengths can be part of long‑term therapeutic support, but it does not address the immediate concern of a possible suicidal statement. Before engaging in broader discussions, the nurse must first determine the meaning and seriousness of the client’s words.

B. Ask the client to clarify what they mean: Asking the client to clarify their statement is the priority because it directly assesses the risk of self‑harm. This step helps the nurse determine whether the client has suicidal ideation, intent, or a plan. Clear assessment of safety concerns must occur before any other supportive or therapeutic interventions.

C. Ask the client if they have been taking their medication as prescribed: Medication adherence is important, but it does not address the urgency of a suicidal comment. Focusing on medications can divert attention from immediate safety needs and delay critical assessment of suicidal risk.

D. Remind the client that it is not the end of life: Offering reassurance without assessing the client’s emotional state can minimize their feelings and discourage further communication. This response may shut down dialogue and does not evaluate the level of risk, which is the most urgent priority.