A nurse is preparing to administer an infusion of packed RBCs through a peripheral IV catheter. Which of the following actions should the nurse take?

A. "Place the bell of the stethoscope on the client's chest." The diaphragm of the stethoscope, not the bell, should be used to auscultate breath sounds because it is designed for high-pitched sounds like lung sounds.
B. "Follow a systematic pattern from side-to-side moving down the client's chest." To accurately compare breath sounds bilaterally, the nurse should use a side-to-side pattern, moving down the chest and back. This ensures a proper assessment of any asymmetry or abnormal sounds.
C. "Ask the client to breathe in deeply through his nose." The client should be instructed to breathe deeply through their mouth, not their nose, to enhance the clarity of breath sounds.
D. "Instruct the client to sit erect with their head tilted slightly backward." The ideal position for auscultating lung sounds is sitting upright with shoulders relaxed and slightly forward, allowing full lung expansion. Tilting the head backward is unnecessary.

The client is most at risk of developing atelectasis and paralytic ileus.

Rationale:

1. Atelectasis – The client has shallow breathing and received IV morphine, which can suppress respiratory effort. Postoperative clients, especially those with abdominal surgery, are at higher risk for atelectasis due to pain-related splinting and immobility.

2. Paralytic Ileus – The client has hypoactive bowel sounds at both assessments, indicating delayed return of bowel function postoperatively. This is common after abdominal surgery, especially with opioid use, and can lead to paralytic ileus.

• Urinary tract infection (UTI) – The client has voided 350 mL of clear yellow urine, indicating normal urinary function post-catheter removal.
• Delayed wound healing – There is no sign of wound complications (dressing remains dry and intact).
• Deep vein thrombosis (DVT) – No signs of unilateral swelling, redness, or pain, and the client is wearing sequential compression devices to prevent DVT.