The nurse reviews the entries in the medical record.

Exhibits

The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.

Explanation:.

• Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
• Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
• Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
• Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
• Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.

. Taking a hot shower in the morning can help decrease stiffness and improve joint mobility for people with rheumatoid arthritis. This is one of the self-management strategies that can reduce pain and disability.

Choice A is wrong because applying cold packs directly on the skin of the affected joints can cause vasoconstriction and increase inflammation.

Cold therapy should be used with caution and with a barrier between the skin and the ice pack.

Choice B is wrong because biological response modifiers are not used to prevent infection, but to reduce inflammation and slow down joint damage in rheumatoid arthritis.

These medications can actually increase the risk of infection by suppressing the immune system.

Choice D is wrong because clustering physical activities during the day can cause fatigue and joint stress for people with rheumatoid arthritis.

It is better to pace activities throughout the day and take frequent breaks to rest the joints.

Normal ranges for rheumatoid arthritis are based on the disease activity score (DAS), which measures the number of swollen and tender joints, the level of inflammation in the blood, and the patient’s global assessment of health. A DAS below 2.6 indicates remission, a DAS between 2.6 and 3.2 indicates low disease activity, a DAS between 3.2 and 5.1 indicates moderate disease activity, and a DAS above 5.1 indicates high disease activity.