The nurse is reviewing the client's medical record.

Exhibits

For each potential nursing action, click to specify if the action is indicated or not indicated.

• Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
• Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
• Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
• Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.

Not Indicated:

• Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
• Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.

A. "Sarcoptes scabiei." Sarcoptes scabiei is the parasitic mite that causes scabies, a contagious skin condition. While scabies is highly transmissible through direct contact, it is not a nationally notifiable disease and does not require mandatory reporting to the state health department.
B. "Impetigo contagiosa." Impetigo is a bacterial skin infection commonly caused by Staphylococcus aureus or Streptococcus pyogenes. Although it is contagious, it is not classified as a reportable disease at the national level, though some local jurisdictions may require reporting in outbreak situations.
C. "Neisseria gonorrhoeae." Gonorrhea is a sexually transmitted infection caused by Neisseria gonorrhoeae and is a nationally notifiable disease. Healthcare providers are required to report cases to public health authorities for surveillance, tracking, and prevention efforts, as untreated gonorrhea can lead to serious complications such as pelvic inflammatory disease, infertility, and neonatal infections.
D. "Human papillomavirus." Human papillomavirus (HPV) is the most common sexually transmitted infection, with multiple strains that can cause genital warts and cervical cancer. Although HPV is a significant public health concern, individual cases are not typically required to be reported to state health departments unless part of a specific surveillance program.