A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift?

A. Remove the client's IV access:

Removing the client's IV access is not the most appropriate initial action when a client experiences difficulty breathing and severe chest tightness during a transfusion. While it's important to discontinue the infusion, the immediate priority is to stop the transfusion itself to prevent further reaction and assess the client's condition.

B. Assess the client's chest sounds and vital signs:

This choice is the correct answer. After stopping the transfusion, the nurse should assess the client's respiratory status by listening to chest sounds for any wheezing or crackles, as well as checking vital signs such as oxygen saturation, respiratory rate, blood pressure, and heart rate. These assessments help evaluate the severity of the reaction and guide further interventions.

C. Notify the client's healthcare provider:

Notifying the healthcare provider is an essential step, but it typically follows the immediate action of stopping the transfusion and assessing the client's condition. The healthcare provider needs to be informed promptly about the client's condition, transfusion reaction, and the actions taken for further guidance and orders.

D. Stop the transfusion immediately:

This is the initial and most critical action when a client experiences signs of a transfusion reaction such as difficulty breathing and severe chest tightness. Stopping the transfusion promptly helps prevent the reaction from worsening and allows for immediate assessment and intervention to ensure client safety.

A. Confirm that the room number matches the medical record.Room numbers should never be used as a sole method to identify a client. Room assignments can change, and relying on them could lead to errors.

B. Compare the client identification number to the blood component tag number.Matching the client identification number to the blood component tag ensures the blood is being administered to the correct client. This is a key step in preventing transfusion errors.

C. Verify the provider's prescription with another RN.While this is an important step in the blood administration process, it is not specifically related to identifying the client.

D. Ask the client to verbalize if the blood type is Rh-negative or positive.Clients may not know their blood type, and relying on their verbal confirmation is unsafe. The blood type must be confirmed through laboratory testing and matched with the blood being administered.

E. Scan the barcode on the client's identification band.Scanning the barcode on the client’s identification band is a reliable and commonly used method for verifying the client’s identity in modern healthcare settings. This ensures that the blood is administered to the correct client.