A nurse is collecting data from a client who has hyperparathyroidism and is receiving 0.9% sodium chloride via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

Rationale:

A. The weights apply a pulling force continuously: Buck’s traction is a form of skin traction used to immobilize fractures and reduce muscle spasms. The weights must hang freely and provide a constant pulling force to maintain alignment and promote healing.

B. The boot allows active leg movement: In Buck’s traction, the affected leg should be immobilized. Active movement would interfere with the consistent traction force and compromise the effectiveness of the treatment.

C. The footplate rests against the foot of the bed: The client’s foot should not press against the bedframe or footplate, as this can counteract the traction force and cause improper alignment. There should be adequate space for traction to be effective.

D. The weights are just touching the floor: Weights should hang freely and never touch the floor. If they rest on the floor, the traction force is lost, defeating the purpose of the setup and potentially leading to complications.

Rationale:

• Document the blood product transfusion in the client’s medical record: It is essential to record the transfusion, including time started and ended, vital signs, and any reactions. Documentation ensures traceability, supports patient safety, and meets regulatory and institutional requirements.

• Monitor the client for the first 15 min of the transfusion: The first 15 minutes are the most critical for detecting transfusion reactions, such as fever, chills, rash, or anaphylaxis. Continuous monitoring during this window allows for prompt intervention if adverse symptoms occur.

• Assist with obtaining the first unit of packed RBCs from the blood bank: RNs or authorized personnel can retrieve blood from the blood bank. Proper handling and timely transport of the blood ensure viability and reduce the risk of hemolysis or temperature-related damage.

• Assist with titrating the rate of infusion to maintain the client’s blood pressure at 90/60 mm Hg or above: Titrating transfusion rates based solely on BP is not within nursing protocol unless specifically ordered. Blood products must be infused according to prescription typically over 2 to 4 hours per unit unless a reaction or complication occurs.

• Start an IV bolus of lactated Ringer’s solution: The provider specifically prescribed a 0.9% sodium chloride bolus. Lactated Ringer’s is contraindicated during transfusions because it contains calcium, which can cause clotting when mixed with blood products.

• Discard the blood bag in the client’s trash can after the transfusion: Blood bags must be disposed of in biohazard containers to comply with infection control policies. Discarding medical waste in general trash violates safety protocols and increases contamination risk.