A nurse is monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?

Choice A rationale

Elevating the head of the bed 45 degrees before starting the CPM device is not necessary. The position of the bed does not affect the operation of the CPM device.

Choice B rationale

Instructing the patient to increase the degree of flexion as tolerated is not the nurse’s responsibility. The degree of flexion is usually set by the healthcare provider or physical therapist.

Choice C rationale

Ensuring the frame joint is in a flexed position before placing the leg onto the device is not necessary. The CPM device should be set up according to the manufacturer’s instructions and the healthcare provider’s orders.

Choice D rationale

Ensuring the knee joint is positioned over the CPM device frame joint is crucial. Proper alignment of the patient’s knee joint with the CPM device’s joint ensures effective and safe operation of the device.

Choice A rationale:

Obtain the client’s weight is an important task, particularly in cases where the client's fluid status needs to be monitored or if weight- based medications are prescribed. However, in this scenario, while monitoring the weight is necessary for assessing fluid balance and the patient's general condition, it does not address the immediate need to investigate the cause of the fever and signs of possible infection. The priority in this situation is to collect data that will guide effective treatment, which is why obtaining blood cultures is critical before any antibiotics are administered. Weight measurement does not directly influence the immediate treatment decisions or diagnostics related to the fever and signs of infection.

Choice B rationale:

Assist with administering the antibiotic is important given the patient's fever and possible infection. Vancomycin is a crucial antibiotic for treating infections, particularly those associated with the arteriovenous fistula (AVF) site. However, it is essential to first obtain blood cultures before starting antibiotics to ensure accurate identification of the causative organism and to guide appropriate antibiotic therapy. Administering the antibiotic before blood cultures are taken may affect the results, making it harder to determine the right treatment. Therefore, while administering the antibiotic is important, it should follow the collection of blood cultures to avoid compromising diagnostic accuracy.

Choice C rationale:

Initiate a nutritional consult is relevant for addressing the patient’s nutritional needs, particularly if there are concerns about malnutrition or dietary deficiencies. In this scenario, the immediate concern is managing the fever and potential infection, rather than addressing nutritional needs. The priority should be to diagnose and manage the infection, which will have a more immediate impact on the patient’s overall condition. Nutritional consultation is important but not the immediate priority when the patient is presenting with signs of infection and a high fever.

Choice D rationale:

Administer acetaminophen is a necessary action to manage the patient’s elevated temperature (39.1°C or 102.4°F). Acetaminophen can help reduce fever and provide symptomatic relief. However, addressing the fever with medication does not resolve the underlying cause. Given the presence of erythema at the AVF site and the need to identify the source of infection, obtaining blood cultures should be prioritized. Treating the fever with acetaminophen before obtaining blood cultures may interfere with the interpretation of the results. Thus, while administering acetaminophen is appropriate for fever management, it should not precede the collection of blood cultures.

Choice E rationale:

Administer diphenhydramine, an antihistamine, is generally used to manage allergic reactions or symptoms such as itching. In this scenario, there is no indication of an allergic reaction or symptoms that would warrant the use of diphenhydramine. The primary concern is the patient’s fever and possible infection at the AVF site. Administering diphenhydramine does not address the infection or fever management in a manner that would influence the immediate treatment plan. Hence, while diphenhydramine might be used for symptomatic relief in other situations, it is not the priority in this context.

Choice F rationale:

Obtain blood cultures is the correct priority because it is crucial for diagnosing the source of infection. The patient presents with a high fever and signs of possible infection at the AVF site. Blood cultures need to be obtained before starting antibiotics to identify the causative organism and tailor the antibiotic treatment accordingly. This step is critical to ensure effective and targeted treatment and to avoid compromising the diagnostic process. Accurate identification of the pathogen through blood cultures will guide the appropriate use of antibiotics and other treatments, making this the first action the nurse should take.