A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

Rationale:

A. "I will restrict my fluid intake to less than 1 L per day." Fluid restriction to less than 1L/day is excessive and unnecessary unless the client has severe fluid retention. The client should follow specific instructions from their healthcare provider regarding fluid intake.

B. "It is important to check my blood pressure at different times of the day." This shows understanding of blood pressure fluctuations. Regular monitoring, especially in those with kidney dysfunction, is important to detect abnormal increases.

C. "I understand that I need to restrict potassium in my diet."Impaired renal function can lead to impaired potassium excretion causing hyperkalemia. Potassium restriction helps prevent cardiac complications from elevated potassium levels.

D. "I will check my weight first thing in the morning." Weighing in the morning gives a consistent baseline to track sudden weight changes, which can indicate fluid retention or worsening kidney function.

E. "I will notify my provider if I suddenly notice weight gain." Rapid weight gain can indicate fluid retention or worsening kidney function. The client should inform their provider if this occurs to prevent complications.

F. "I only need to check my weight weekly." Daily weight monitoring is more appropriate for clients with kidney or heart conditions to detect sudden fluid retention. Weekly checks may miss early signs of fluid retention.

Rationale:

A. "Initiate venous access with a 21-gauge needle." For blood transfusions, it is recommended to use a larger gauge needle, 18-20 gauge, to allow for proper blood flow and reduce the risk of hemolysis. A 21-gauge needle is too small for optimal transfusion.

B. "Obtain the client's first set of vital signs 1 hr after initiating the transfusion." The first set of vital signs should be obtained immediately before starting the transfusion, and then monitored every 15 minutes to detect any early signs of a transfusion reaction.

C. "Administer the unit of packed RBCs over 1 hr." The unit of packed RBCs should be administered over 4 hours to reduce the risk of transfusion reactions and allow for optimal oxygen-carrying capacity. Infusing blood too quickly can cause complications such as volume overload or reactions.

D. "Use Y tubing with 0.9% sodium chloride when administering the transfusion." Y tubing is commonly used for blood transfusions to allow for the infusion of normal saline (0.9% sodium chloride) alongside the blood product. This helps maintain the flow of the transfusion and reduces the risk of clot formation while flushing the line.