An adult male client is admitted to the medical unit because of a loss of appetite and generalized malaise. His complete blood count (CBC) results indicate a white blood cell (WBC) count of 8,000/mm³ (8 x 10⁹/L), basophils 1% (0.01 fraction), platelets 98,000/mm³ (98 x 10⁹/L), hemoglobin of 14 g/dL (8.7 mmol/L), and hematocrit of 44.9% (0.44 volume fraction). The practical nurse (PN) should assess the client for which finding?

Reference Range:

• White Blood Cell (WBC): 5,000 to 10,000/mm³ (5 to 10 x 10⁹/L)
• Basophils: 0.5 to 1.0% (0.01 to 0.05 x 10⁹/L)
• Platelets: 150,000 to 400,000/mm³ (150 to 400 x 10⁹/L)
• Hemoglobin (Hgb): 14 to 18 g/dL (8.69 to 11.17 mmol/L)
• Hematocrit (Hct): 42% to 52% (0.42 to 0.52 volume fraction)

Choice A reason: Administering a PRN prescription for an antiemetic might help with the nausea and vomiting, but it is not the first action to take. The primary concern should be addressing a potential transfusion reaction.
Choice B reason: Flushing the IV tubing with sodium chloride is an important step to clear the line of any remaining blood product, but this should be done after stopping the infusion to prevent further administration of the blood.
Choice C reason: Notifying the healthcare provider is crucial, but the first and most immediate action should be to stop the blood infusion to prevent further reaction.
Choice D reason: Turning off the blood infusion is the first and most critical action to take. Shaking, nausea, and vomiting can be signs of a transfusion reaction, and halting the infusion immediately helps prevent further complications. Following this, the nurse should notify the healthcare provider and take other appropriate measures.

Choice A reason: Suction equipment is essential for a client who has undergone fixation of a mandible fracture. Due to the nature of the surgery and the presence of wiring, the client may have difficulty managing oral secretions. Suction equipment ensures that any secretions can be promptly and effectively removed, preventing aspiration and maintaining a clear airway. This equipment is vital for managing the client's immediate postoperative needs and ensuring their safety.
Choice B reason: A crash cart, while critical in emergency situations, is not specifically required to be present in the client's room following mandible fracture fixation. Crash carts are typically available on the unit and can be quickly brought to the room if needed. The practical nurse should be familiar with the location of the crash cart and how to access it, but it does not need to be permanently stationed in the client's room.
Choice C reason: A non-rebreather mask is used to deliver high concentrations of oxygen to clients experiencing severe respiratory distress or hypoxemia. While it is an important piece of equipment for respiratory emergencies, it is not specifically necessary to have in the room of a client with a mandible fracture fixation. The priority is to have suction equipment and wire cutters immediately available, while other oxygen delivery devices can be accessed as needed.
Choice D reason: A nasogastric tube is used for decompression of the stomach or for feeding clients who are unable to take oral nutrition. It is not specifically required for a client with a mandible fracture fixation unless there are additional complications or indications for its use. The practical nurse should focus on equipment directly related to managing the fixation and maintaining the client's airway.
Choice E reason: Wire cutters are a critical item to have in the room of a client with a mandible fracture fixation. In the event of an emergency, such as vomiting or respiratory distress, the wires securing the mandible may need to be quickly cut to ensure the client's airway is not compromised. Having wire cutters immediately available ensures that the practical nurse can respond swiftly and effectively to any urgent situations, maintaining the client's safety and airway patency.