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: Checking mucous membranes can provide information about the client's hydration status. Dry mucous membranes can be a sign of dehydration, which may contribute to decreased urine output. This assessment is important to determine whether the client has adequate fluid balance.
Choice B reason: Ensuring that the catheter tubing is straight is essential to confirm that there are no kinks or obstructions that could be causing the reduced urine flow. Any obstruction in the catheter tubing could lead to a sudden decrease in urine output, and this check helps ensure patency.
Choice C reason: Auscultating lung sounds is crucial to assess for fluid overload or pulmonary complications, which can be associated with renal transplant patients. Abnormal lung sounds could indicate issues that may indirectly affect urine output and overall kidney function.
Choice D reason: Determining the dryness of bed linens helps assess whether the client might have experienced a leakage of urine outside the catheter system. If the bed linens are wet, it could indicate an issue with the catheter or bladder function that needs to be addressed.
Choice E reason: Irrigating the catheter to assess patency is a direct method to determine whether there is any blockage or obstruction in the catheter. This procedure helps ensure that the catheter is functioning correctly and allows for appropriate urine drainage.

Choice A reason: Applying direct pressure over the area that is bleeding is a general first aid measure to stop bleeding. However, in the context of obtaining a fingerstick blood sugar, this action is not the immediate next step. The objective of the fingerstick is to obtain a sample of blood for testing blood glucose levels. Applying pressure would stop the flow of blood, making it difficult to obtain a sufficient sample for the test.
Choice B reason: Wiping off the drop of blood with a gauze pad is not recommended after pricking the finger for a blood glucose test. Removing the initial drop of blood could result in the need to squeeze the finger again, potentially causing hemolysis (breaking of blood cells) and leading to an inaccurate reading. It is important to use the initial drop of blood for the test to ensure accurate results.
Choice C reason: Cleaning the finger with an alcohol prep pad before pricking is a standard step to ensure that the area is free from contaminants and to prevent infection. However, doing this after the drop of blood is visible is unnecessary and can interfere with the sample. Alcohol residue can affect the accuracy of the blood glucose reading. Therefore, cleaning should be done prior to pricking, not after the blood is obtained.
Choice D reason: Applying the drop of blood to the test strip is the correct action to take. Once the drop of blood is visible, it should be applied to the test strip immediately to obtain a blood glucose reading. This ensures that the sample is fresh and uncontaminated, providing an accurate measurement of the client's blood sugar levels. This step is essential for effective monitoring and management of diabetes.