A nurse is caring for a 59-year-old male client in the intermediate care unit.

Exhibits

Which of the following findings requires the nurse's immediate attention?

TRALI is a life-threatening condition associated with blood transfusion. The client’s symptoms, including trauma and low hemoglobin, indicate the need for transfusion. TRALI can cause acute respiratory distress shortly after transfusion. Early intervention can improve outcomes. Recognizing the signs of TRALI is essential in such scenarios.

Rationale for actions

Administer oxygen: Oxygen supplementation can help manage hypoxemia associated with TRALI. It ensures adequate oxygenation during respiratory distress. Monitor for respiratory distress: Continuous assessment helps detect worsening symptoms. Early detection can prompt timely intervention. Rationale for parameters: Oxygen saturation: Monitoring SpO2 provides real-time information on the patient’s oxygenation status. It helps determine the effectiveness of oxygen therapy. Heart rate: Tachycardia can indicate worsening respiratory distress or hypoxemia. Monitoring heart rate is crucial for early detection of complications.

Rationale for incorrect conditions

Transfusion-associated circulatory overload (TACO): TACO involves fluid overload, leading to cardiac symptoms. However, this client’s presentation suggests acute lung injury, not fluid overload. Incorrect conditions (others): Abandonment: Not applicable as the client was brought to the hospital and received care. Physical abuse: No evidence of physical abuse in this case. Self-neglect: The client is a child, and the injury was accidental, not due to neglect. The parents brought him to the hospital promptly.

Choice A rationale

Informing the client that the nurse is busy and will talk to him later is a professional and appropriate response. This approach acknowledges the client's need for attention while setting a clear boundary that respects the nurse's current responsibilities. It also provides a time frame for when the client can expect to receive attention, which can help reduce anxiety or agitation. This method promotes orderly and efficient care without compromising the needs of the newly admitted client.

Choice B rationale

Putting the client's behavior on extinction by not acknowledging it might seem effective, but it can lead to feelings of being ignored or dismissed. This approach is not therapeutic in a psychiatric setting, where clients often require validation and structured interactions. Ignoring a client's request can escalate the behavior or contribute to a sense of isolation. Therapeutic communication involves active listening and responding appropriately to all clients.

Choice C rationale

Introducing the client to the newly admitted client and asking him to join the conversation can be disruptive and inappropriate. This action may not address the urgency of the client's concern and can intrude on the privacy and focus needed for the newly admitted client. It is important to maintain a structured and private environment for admissions to ensure that the new client feels supported and understood.

Choice D rationale

Encouraging the client to go to the nurse's station and talk with another nurse may not be practical, especially if the other nurses are also occupied. This response can seem dismissive and may not adequately address the client's immediate concern. It is more effective to provide a clear time frame or alternative solution for when the client will receive attention. Proper delegation requires ensuring that the alternative option is available and can provide the necessary support.