A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

Rationale
1. Stay with the client for the first 15 minutes of the transfusion.

Indicated
This is a standard protocol for blood transfusions. The first 15 minutes of the transfusion are the most critical because acute transfusion reactions (such as allergic reactions, febrile reactions, or hemolysis) are most likely to occur during this time. By staying with the client, the nurse can monitor for any signs of reaction (e.g., fever, chills, shortness of breath, rash) and intervene immediately if necessary.

2. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

Indicated
Given the client’s low blood pressure (hypotension), it is important to monitor and potentially titrate the rate of infusion during the blood transfusion. The nurse should ensure that the blood pressure is maintained at an acceptable level. Blood transfusions can cause fluid shifts and affect hemodynamics, so the nurse may adjust the transfusion rate based on the client's vital signs to maintain adequate blood pressure and avoid complications, such as fluid overload or inadequate tissue perfusion.
3. Obtain the first unit of packed RBCs from the blood bank.

Indicated
The client is being prepared for a blood transfusion, so obtaining the blood product from the blood bank is a necessary step. The nurse must ensure that the correct blood product (two units of packed RBCs) is ordered, cross-matched, and ready for administration. Blood verification is critical to avoid transfusion errors, and this step is essential for the transfusion process.
4. Start an IV bolus of lactated Ringer's solution.
The provider’s prescription specifies a 500 mL bolus of normal saline (0.9% sodium chloride), not lactated Ringer's solution. Normal saline is preferred for blood transfusions because it does not contain calcium, which can bind to the citrate in blood products and cause clotting or other complications. Using the correct IV solution is essential for safety.
5. Document the blood product transfusion in the client's medical record.

Indicated
Proper documentation is essential in nursing practice. The nurse must record key information regarding the blood transfusion, including the type of blood product, the date and time of transfusion, the rate of infusion, and any reactions or complications. Documentation helps ensure continuity of care, and it is required by legal and institutional standards.

A. Hypotension is not typically associated with acute glomerulonephritis. Instead, hypertension is more commonly seen due to fluid retention and increased vascular resistance.
B. Hematuria is a hallmark finding of acute glomerulonephritis. This condition often leads to blood in the urine, which can be seen as reddish or smoky-colored urine.
C. Weight loss is not typically associated with acute glomerulonephritis. Weight gain is more common due to fluid retention and edema caused by impaired kidney function.
D. Polyuria (excessive urination) is generally not expected in acute glomerulonephritis. Instead, oliguria (decreased urine output) is more typical, as kidney function is impaired and fluid retention occurs.