A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Rationale:

A. "Initiate venous access with a 21-gauge needle." For blood transfusions, it is recommended to use a larger gauge needle, 18-20 gauge, to allow for proper blood flow and reduce the risk of hemolysis. A 21-gauge needle is too small for optimal transfusion.

B. "Obtain the client's first set of vital signs 1 hr after initiating the transfusion." The first set of vital signs should be obtained immediately before starting the transfusion, and then monitored every 15 minutes to detect any early signs of a transfusion reaction.

C. "Administer the unit of packed RBCs over 1 hr." The unit of packed RBCs should be administered over 4 hours to reduce the risk of transfusion reactions and allow for optimal oxygen-carrying capacity. Infusing blood too quickly can cause complications such as volume overload or reactions.

D. "Use Y tubing with 0.9% sodium chloride when administering the transfusion." Y tubing is commonly used for blood transfusions to allow for the infusion of normal saline (0.9% sodium chloride) alongside the blood product. This helps maintain the flow of the transfusion and reduces the risk of clot formation while flushing the line.

Rationale:

A. Raise the head of the bed to 45° prior to insertion: The head of the bed should not be raised to 45° prior to catheter insertion. The client should be in a comfortable, supine position with the legs slightly apart to facilitate proper catheter insertion.

B. Secure the catheter to the client's inner thigh: Securing the catheter to the client's inner thigh helps prevent tension on the catheter and reduces the risk of discomfort or accidental dislodgement. This is a standard practice for catheter care.

C. Attach the bag to the rail of the bed: The urinary drainage bag should never be attached to the bed rail, as it could lead to the backflow of urine into the bladder, increasing the risk of infection. The bag should be placed lower than the bladder and secured to the bed frame.

D. Collect a urine specimen from the drainage bag 1 hr after insertion: Urine specimens should not be collected from the drainage bag because the urine in the bag may be contaminated. A clean-catch specimen or a specimen collected directly from the catheter should be used for accurate testing.