A client with heart failure requests two more pillows to sleep with at night. Which area should the practical nurse (PN) evaluate when responding to the client's request?

Choice A reason: Administering a PRN prescription for an antiemetic might help with the nausea and vomiting, but it is not the first action to take. The primary concern should be addressing a potential transfusion reaction.
Choice B reason: Flushing the IV tubing with sodium chloride is an important step to clear the line of any remaining blood product, but this should be done after stopping the infusion to prevent further administration of the blood.
Choice C reason: Notifying the healthcare provider is crucial, but the first and most immediate action should be to stop the blood infusion to prevent further reaction.
Choice D reason: Turning off the blood infusion is the first and most critical action to take. Shaking, nausea, and vomiting can be signs of a transfusion reaction, and halting the infusion immediately helps prevent further complications. Following this, the nurse should notify the healthcare provider and take other appropriate measures.

Choice A reason: Commending the client for ensuring an adequate source of vitamin C in the diet is not the best response. While vitamin C is important for overall health, it does not directly impact bone density. The client's focus on orange juice may stem from a misunderstanding of the nutrients that are critical for bone health, such as calcium and vitamin D. A better approach would be to address the specific nutrients that support bone density and clarify any misconceptions.
Choice B reason: Advising the client of the need to remain NPO (nothing by mouth) until the test is completed is not necessary for a bone density test. Bone density tests, such as dual-energy X-ray absorptiometry (DEXA) scans, do not require the client to fast beforehand. Providing this advice would be incorrect and could cause unnecessary concern or confusion for the client.
Choice C reason: Determining if the client drinks orange juice that has been fortified with calcium is a helpful step, but it does not address the immediate need to correct the client's misunderstanding about the purpose of the bone density test. While calcium-fortified orange juice can be beneficial for bone health, the priority should be to ensure the client has accurate information about the test they are undergoing.
Choice D reason: Correcting the client's misunderstanding of the purpose of bone density testing is the most appropriate response. The primary goal of a bone density test is to measure the density of the bones and assess the risk of fractures, not to diagnose or confirm the presence of osteoporosis. By providing clear and accurate information about the test, the practical nurse can help the client understand its purpose and alleviate any misconceptions. This response also opens the door for further education on managing osteoporosis and ensuring the client is receiving the necessary nutrients for bone health.