A client is receiving a unit of packed red blood cells (PRBCs). Which is the first action the practical nurse (PN) should take if the client begins to shake and reports feelings of nausea and vomiting?

Choice A reason: Asking the client about any changes in vision can provide valuable information regarding the client's subjective experience and any potential progression of cataracts. However, given the observation of milky white pupils, which may indicate a more serious issue such as advanced cataracts or another underlying condition, it is crucial to take immediate and appropriate action. While gathering subjective data is important, notifying the charge nurse ensures that the finding is promptly addressed by the healthcare team.
Choice B reason: Notifying the charge nurse of the finding is the most appropriate action in this scenario. The observation of milky white pupils in a client with cataracts could indicate significant changes or complications that require further evaluation and potential intervention. By promptly reporting this finding to the charge nurse, the practical nurse ensures that the client receives timely and appropriate care, including potential diagnostic tests and consultations with specialists if necessary.
Choice C reason: Assisting the client to a semi-Fowler's position can be beneficial for comfort and to facilitate breathing, especially in bedfast clients. However, this action does not directly address the observation of milky white pupils. The immediate priority is to notify the charge nurse to ensure that the finding is properly evaluated and managed. Positioning the client can be done as part of routine care, but it is not the most urgent response to the observed change.
Choice D reason: Assessing the client using the Glasgow Coma Scale (GCS) is appropriate for evaluating the level of consciousness and neurological status. However, in this context, the observation of milky white pupils is more likely related to an ocular condition rather than a neurological issue. While it is always important to monitor the client's overall status, the immediate priority is to report the finding to the charge nurse for appropriate ocular assessment and management.

Choice A reason: Flushed, hot skin is not directly related to the client's CBC results. This symptom can indicate various conditions, such as fever, inflammation, or an allergic reaction, but it does not specifically correlate with the lab findings provided. The client's WBC count, hemoglobin, hematocrit, and basophils are within normal ranges, and the most significant abnormality is the low platelet count.
Choice B reason: Hives, or urticaria, are typically associated with allergic reactions and not directly related to the client's CBC results. While a low platelet count can sometimes be associated with immune-mediated conditions, hives are not a primary symptom of thrombocytopenia (low platelet count). The main concern with a low platelet count is the increased risk of bleeding and bruising.
Choice C reason: Inelastic turgor is a sign of dehydration or poor skin elasticity, often seen in conditions such as severe dehydration or malnutrition. The client's CBC results do not indicate dehydration or issues with skin turgor. The hemoglobin and hematocrit levels are within normal ranges, suggesting that the client's overall fluid status is likely stable.
Choice D reason: Bruising is the most relevant finding to assess for in a client with a low platelet count (thrombocytopenia). Platelets play a crucial role in blood clotting, and a low platelet count increases the risk of bleeding and easy bruising. The client's platelet count of 98,000/mm³ (98 x 10⁹/L) is below the normal range, which predisposes them to bruising and potential bleeding complications. It is important for the practical nurse to assess for signs of bruising and bleeding and to monitor the client closely for any further complications.