The nurse is collecting data from the client following the transfusion of 2 units of packed RBCs.

Exhibits

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Laboratory Results:

1800:

WBC count 6,700/mm (5,000 to 10,000/mm3)

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Vital Signs:

1800:

Blood pressure 112/74 mm Hg

Heart rate 95/min

Respiratory rate 18/min

Temperature 37.5°  C (99.5°  F)

O2 saturation 100% 2 L/min O2 via nasal cannula

Assessment:

1800:

Physical Exam

General: no distress

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pink

Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding

Neurologic: awake and alert

Anticipated:

• Apply a cool compress to the extremity. A cool compress can reduce swelling, relieve discomfort, and help minimize the tightness in the skin caused by edema. The cold temperature helps constrict blood vessels, reducing fluid buildup in the tissues. This intervention is appropriate for managing IV infiltration-related symptoms.
• Assist in inserting a new IV catheter in a site distal to the infiltration site. If the IV site becomes infiltrated, the correct approach is to stop the current infusion and insert a new catheter in a different location, preferably distal to the infiltration site. This ensures continued IV access without further aggravating the infiltrated site.
• Elevate extremity. Elevating the affected extremity can help reduce swelling by promoting venous return. Elevation improves circulation and decreases the pressure caused by fluid accumulation in the tissues. This is an effective intervention for managing swelling in the right upper extremity due to infiltration.

Not Anticipated:

• Phytonadione (vitamin K) is typically used to reverse the effects of anticoagulation medications or treat vitamin K deficiency. This is not indicated for the client, as there is no evidence of bleeding or an anticoagulation issue that requires vitamin K. The client's current problem is an IV infiltration, not a clotting disorder.
• Send the catheter tip for culture. At this point, there are no signs of infection such as redness, warmth, or discharge from the IV site. The primary concern is managing the infiltration, so sending the catheter tip for culture is unnecessary unless infection is suspected. Culture collection is reserved for cases where an infection is present.
• Suggest irrigating the IV catheter. Irrigating an infiltrated IV catheter could worsen the situation by pushing fluids further into the surrounding tissue or introducing bacteria. The proper action is to discontinue the infusion, remove the IV, and insert a new catheter at a different site rather than attempting to irrigate an already compromised catheter.

A chest x-ray is an essential diagnostic tool for evaluating a client with symptoms such as a productive cough, blood-tinged sputum, weight loss, night sweats, and a low-grade fever. These findings raise suspicion for tuberculosis (TB), particularly given the client’s recent travel to South Africa, where TB is more prevalent. A chest x-ray can help identify characteristic abnormalities such as upper lobe infiltrates, cavitations, or pleural effusions that are consistent with pulmonary TB.

A nasopharyngeal swab is primarily used to detect viral respiratory infections, such as influenza or COVID-19. While the client presents with a cough and fever, the chronic nature of symptoms and presence of hemoptysis make a viral infection less likely. Furthermore, viral infections typically present with acute onset symptoms rather than a prolonged illness with weight loss and night sweats.

Blood cultures are used to identify systemic bacterial infections, such as bacteremia or sepsis. Although the client has a fever, there are no indications of severe systemic infection, such as hypotension or signs of shock, making blood cultures a lower priority in this case.

A pulmonary function test evaluates lung function in conditions such as asthma or chronic obstructive pulmonary disease (COPD). The client has no history of these conditions, and their primary complaint involves symptoms suggestive of an infectious process rather than an obstructive pulmonary disease. Pulmonary function testing is not indicated for diagnosing TB or other respiratory infections.

A Mantoux test (tuberculin skin test) is a key diagnostic tool in assessing tuberculosis exposure. Given the client’s symptoms and travel history, this test helps determine prior exposure to Mycobacterium tuberculosis and the likelihood of latent or active infection. A positive test would support further diagnostic testing, such as sputum cultures, to confirm active TB disease.