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

Raspberries are an excellent source of dietary fiber, with approximately 8 grams of fiber per cup. They are rich in both soluble and insoluble fibers, which help promote healthy digestion and bowel regularity. The high fiber content in raspberries can help prevent and alleviate constipation, which is particularly beneficial for individuals with hemorrhoids.

Choice B rationale

Oatmeal is another high-fiber food, providing about 4 grams of fiber per cup. It contains a type of soluble fiber called beta-glucan, which forms a gel-like substance in the intestines, helping to soften stool and improve bowel movements. Including oatmeal in the diet can help reduce the discomfort associated with hemorrhoids.

Choice C rationale

Scrambled eggs are a good source of protein but are low in dietary fiber. They do not contribute to increasing the fiber intake needed to alleviate hemorrhoid symptoms. Although they can be part of a balanced diet, they are not specifically beneficial for a high-fiber diet.

Choice D rationale

Bacon slices are high in fat and low in fiber. Consuming high-fat foods can lead to constipation, which can worsen hemorrhoid symptoms. Bacon does not provide the necessary fiber to promote healthy digestion and bowel movements.

Choice E rationale

Raisin bran muffins are a high-fiber food option, with both the bran and raisins contributing to their fiber content. Bran is rich in insoluble fiber, which adds bulk to the stool and helps prevent constipation. Raisins also contain fiber, making raisin bran muffins a suitable choice for individuals with hemorrhoids.