A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

A. Inserting an indwelling catheter involves an invasive procedure and assessment of urinary output and client status, which falls within the RN’s scope of practice in a high-risk client such as one with acute liver failure.

B. Obtaining abdominal girth requires assessment skills and interpretation for changes in ascites, which is more appropriate for the RN to ensure accurate monitoring.

C. Assessing and documenting level of consciousness is a critical assessment, especially in liver failure where hepatic encephalopathy is a risk. This is within the RN’s responsibility because changes can be subtle and require immediate intervention.

D. Measuring the amount of gastric drainage every 2 hours is a stable, routine task that follows established parameters and does not require advanced assessment skills. It is within the LPN’s scope and can be safely delegated, with the RN overseeing interpretation of any abnormal findings.

A.

A. Brainstorming sessions with nurses can generate new ideas and perspectives to address public health concerns such as rising rates of sexually transmitted infections. It allows for creative

thinking and collaboration among team members.

B. While a community-wide program may be part of the solution, it may not directly involve generating new ideas within the healthcare team.

C. Role-playing with nurses may be beneficial for training and education purposes but may not specifically focus on generating new ideas to address the public health concern.

D. Personal discussions with clients may provide valuable insights into individual experiences and needs but may not be the most effective method for generating new ideas on a broader scale to address community-wide concerns.