A nurse is performing a skin assessment for a client who has been on bed rest for 1 week. The nurse notes reddened areas on the client's scapulae. Which of the following actions should the nurse take?

A. Administer the unit of packed RBCs over 1 hr: Transfusing packed RBCs too quickly increases the risk of fluid overload and cardiovascular complications. Standard practice is to administer the unit over 2 to 4 hours, with careful monitoring for adverse reactions.

B. Obtain the client's first set of vital signs 1 hr after initiating the transfusion: Vital signs should be obtained immediately before starting the transfusion, then monitored closely during the first 15 minutes, when most acute transfusion reactions occur. Waiting an hour could delay recognition of complications.

C. Use Y tubing with 0.9% sodium chloride when administering the transfusion: Y tubing with normal saline is the correct method for administering packed RBCs. Saline maintains patency of the line and prevents incompatibility reactions, as other IV solutions can cause hemolysis or chemical reactions with the blood product.

D. Initiate venous access with a 21-gauge needle: A 21-gauge needle is too small for safe administration of packed RBCs, as it can cause hemolysis. A larger gauge needle, typically 18–20 gauge, is recommended to ensure smooth transfusion and minimize cell damage.

A. Inject the irrigation solution slowly into the catheter: Slowly injecting the irrigation solution prevents sudden increases in bladder pressure, reduces discomfort, and ensures effective clearance of clots or debris. Gentle administration is essential for maintaining the integrity of the bladder and catheter system.

B. Place the client in the Trendelenburg position: The Trendelenburg position is not recommended for routine closed intermittent catheter irrigation. Placing the client in this position can increase the risk of reflux or discomfort and is not necessary for effective irrigation.

C. Clamp the catheter above the specimen port: Clamping the catheter above the specimen port is not appropriate because it can obstruct flow and increase the risk of backflow or bladder distention. The irrigation should be performed using the designated irrigation port while maintaining a closed system.

D. Use a 3-mL syringe to perform the catheter irrigation: A 3-mL syringe is too small for effective bladder irrigation. Typically, a larger syringe (e.g., 30–50 mL) is used to ensure adequate flow of the irrigation solution and clearance of debris without excessive pressure.