A nurse is administering Packed Red Blood Cells (PRBC) to a client who reports having lower back pain and feeling chilled and itchy.
Which of the following actions should the nurse take first?

Choice A rationale

While the client’s daughter, who is the primary caregiver, may have a significant role in the client’s care, the decision to sign the informed consent ultimately lies with the client if they are deemed competent.

Choice B rationale

The client, who is alert and oriented to person, place, and time, and has advance directives, is the most appropriate person to sign the informed consent. As long as the client is competent and understands the information provided, they have the right to make their own medical decisions.

Choice C rationale

The client’s partner does not have the legal authority to sign the informed consent on behalf of the client unless the client is deemed incompetent and the partner is designated as the legal representative.

Choice D rationale

The client’s son, who has a durable power of attorney, can only sign the informed consent on behalf of the client if the client is deemed incompetent. Since the client is alert and oriented, they should be the one to sign the informed consent.

Choice A rationale

Tarry stools are not a typical manifestation of cirrhosis. They are more commonly associated with gastrointestinal bleeding.

Choice B rationale

Spider angiomas are a common manifestation of cirrhosis. They are small, dilated blood vessels with a bright red center point and radiating branches, and they are often found on the face, neck, and chest.

Choice C rationale

Moist skin is not a typical manifestation of cirrhosis. Cirrhosis can cause various skin changes, but they typically include jaundice, pruritus, and palmar erythema.

Choice D rationale

Blood in the urine is not a typical manifestation of cirrhosis. It is more commonly associated with urinary tract infections, kidney stones, or bladder disorders.