A client with a tentative diagnosis of a gastric ulcer is scheduled for an endoscopy. Which concern should the practical nurse (PN) expect this client to have after the procedure is completed?

Choice A reason: Administering a PRN prescription for an antiemetic is not the first action to take in this situation. Shaking and feelings of nausea and vomiting during a blood transfusion can indicate a possible transfusion reaction, which is a serious and potentially life-threatening event. While managing symptoms like nausea is important, the immediate priority is to stop the transfusion to prevent further complications.
Choice B reason: Flushing the IV tubing with sodium chloride is not the appropriate first step. Before addressing the IV line, it is crucial to stop the blood infusion to prevent any more blood from entering the client's system, which could exacerbate a potential transfusion reaction. After stopping the infusion, flushing the line can be considered to maintain IV access, but it is not the initial action to take.
Choice C reason: Notifying the healthcare provider is necessary, but it is not the first action to take. Immediate intervention is required to prevent further administration of the potentially problematic blood product. Once the infusion is stopped, the healthcare provider should be notified promptly so that appropriate assessments and interventions can be initiated.
Choice D reason: Turning off the blood infusion is the first and most critical action to take. This step immediately stops the administration of the blood product, preventing further exposure to the potential cause of the reaction. Once the infusion is stopped, the PN can then proceed to assess the client's vital signs, notify the healthcare provider, and follow the institution's protocol for managing transfusion reactions. Ensuring the client's safety by stopping the infusion is the top priority.

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.