A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?

Serotonin syndrome is a serious drug reaction that results from having too much serotonin in the body. Serotonin is a chemical that plays a role in mood, sleep, appetite and other functions. Some medications, especially antidepressants, can increase serotonin levels and cause serotonin syndrome. The client is taking paroxetine, which is a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). SSRIs work by blocking the reabsorption of serotonin in the brain, making more serotonin available.

Paroxetine can cause serotonin syndrome if taken at high doses, in combination with

other serotonergic drugs, or if abruptly stopped. The client’s symptoms of restlessness, abdominal pain, disorientation and fever are consistent with serotonin syndrome. Other possible symptoms include agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, muscle twitching, rigidity, sweating and shivering. Severe serotonin syndrome can lead to seizures, coma and death. The client should stop taking paroxetine and seek immediate medical attention. Serotonin syndrome can be treated with supportive care and medications that reduce serotonin levels or block its effects. The client may need to switch to a different antidepressant or adjust the dosage under the guidance of their provider.

A. Contact precautions are not indicated based on the assessment findings provided.

Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.

C. a deep tendon reflex (DTR) grade of 3+ indicates a brisker than average response, which could be normal or potentially indicative of neurological hyperactivity. In such cases, creating a calming environment, which may include dimmed lighting, could potentially help in reducing stimuli that might exacerbate neurological excitability.
D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F. Preeclampsia can have adverse effects on fetal well-being, including intrauterine growth restriction and placental insufficiency. However, an external fetal monitoring provides a more accurate assessment of fetal heart rate patterns and allows for closer monitoring of fetal status in cases of maternal hypertension.
G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.