A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

A. Use tubing that does not have a filter in the drip chamber. Blood transfusion tubing must have a filter to trap clots, cellular debris, and other particulates, ensuring the safe administration of blood products.
B. Use an IV catheter that is at least 24-gauge. A larger bore catheter (18- to 20-gauge) is preferred for blood transfusions to reduce the risk of hemolysis and allow adequate flow. A 24-gauge is too small for standard transfusion protocols.
C. Attach a single line administration set. A Y-type tubing set is typically used, allowing for connection to both the blood product and normal saline. This setup enables flushing before and after the transfusion and provides a safe delivery system.
D. Prime the tubing with 0.9% sodium chloride. Only 0.9% sodium chloride (normal saline) should be used to prime the tubing, as it is compatible with blood products and prevents hemolysis or clot formation. Dextrose or other solutions can cause serious reactions.

A. Allow the second nurse to enter the data while observing them. Even if observed, allowing another person to use a computer while logged in under someone else’s credentials violates HIPAA and security policies.
B. Log off the computer and let the second nurse log on and enter the data. This is the correct and secure action. Each nurse must use their own login to ensure accountability and protect patient confidentiality, as required by HIPAA and institutional policies.
C. Ask the second nurse for the data and enter it for them. This may lead to documentation errors or confusion about who provided care. Each nurse should document their own assessments and interventions.
D. Tell the second nurse to enter the data when they return from their break. While delaying documentation is sometimes necessary, timely documentation is important for safe patient care. The second nurse should have the opportunity to chart promptly, but under their own credentials.