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Allergic – An allergic reaction typically presents with itching, rash, and wheezing rather than fever, chills, and hematuria.

Acute pain – Acute pain transfusion reaction is rare and mainly presents with severe chest, back, and joint pain, without fever or hematuria.

Febrile – Febrile reactions cause fever and chills but do not typically cause hematuria, which is indicative of hemolysis.

WBC 8,000 mm³ – Normal white blood cell count; does not explain increased bruising.

Hemoglobin 13.0 g/dL – Normal hemoglobin level; not related to bruising.

RBC 4.6 million/mm³ – Normal RBC count; does not indicate a bleeding risk.

Encourage the patient to ask for assistance. – Patients with Alzheimer's often forget to ask for help, making this an unreliable safety measure.

Keep the call light near the patient. – The patient may not remember to use the call light.

Remind the patient to walk with someone for support. – Reminders may not be effective due to memory impairment.

Suggest the visitors stay a bit longer to provide support and distraction. – Noise and stimulation can worsen migraines.

Suggest the patient ambulates in the hallway to become fatigued, so they can rest. – Movement may increase pain.

Turn on the television to be used as a distractor for the patient. – Bright lights and sound can aggravate symptoms.

Neutropenic – Used for low WBC count, not platelets.

Contact – Used for infections like C. diff or MRSA.

Droplet – Used for respiratory illnesses like flu or meningitis.

Chart – Contains patient information but is not used for immediate verification before transfusion.

Order sheet – Ensures the transfusion is ordered but does not confirm patient identity.

Medication administration record – Lists medications but is not used to verify transfusion identity.

Give potassium intravenously. – The potassium level is 3.7 (within normal range 3.5–5.0), so potassium is not needed yet.

Administer 3% NS at 200 mL/hr. – Hypertonic saline is used for severe hyponatremia, which is not the case here.

Expect the insulin drip to be discontinued. – The insulin drip is not discontinued until ketoacidosis has fully resolved (when HCO3 > 18, pH > 7.3, and anion gap normalizes).

Incorrect → Insulin injections should be administered at a 90-degree angle unless the patient has minimal subcutaneous fat, in which case a 45-degree angle is used. A 25-degree angle is too shallow and may lead to improper absorption.

Incorrect → Insulin should be administered with a U-100 insulin syringe (not a 1 mL syringe) to ensure accurate dosing.

Incorrect → While injecting an inch away from a previous site is reasonable, the preferred practice is rotating between different anatomical sites to prevent tissue damage and inconsistent absorption.

Incorrect → Weight gain (even if minor) can indicate poor glucose control, especially if linked to fluid retention or insulin resistance.

Incorrect → A Hemoglobin A1c of 8.1% is above the target range (typically <7% for diabetics) and indicates poor blood glucose control over the past 2-3 months.

Incorrect → A reddened area on the sole of the foot suggests early signs of diabetic foot complications and possible neuropathy or poor circulation, requiring intervention.

Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.

Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.

Administering an enema daily – Incorrect. This is not a priority in unconscious patients.