The nurse is assessing a patient with peritonitis. What findings should they expect? (Select all that apply)

Choice A reason: Checking the client’s temperature hourly monitors for transfusion reactions but does not prevent them. Fever may indicate a reaction, but prevention relies on ensuring blood compatibility and proper administration. Monitoring is a reactive measure, not a proactive step to avoid mismatches or errors causing hemolytic or febrile reactions.

Choice B reason: Verifying the client’s identity and blood type with another nurse is critical to prevent transfusion reactions. Mismatched blood types cause hemolytic reactions due to antibody-mediated destruction of donor red cells. Double-checking ensures the correct blood unit is administered, preventing life-threatening immunological responses and ensuring patient safety during transfusion.

Choice C reason: Administering diphenhydramine may prevent mild allergic reactions to blood transfusions, such as hives, but it does not address severe hemolytic reactions caused by ABO incompatibility. It is not routinely given prophylactically unless the client has a history of allergic reactions, making it less critical than verifying blood compatibility.

Choice D reason: Infusing blood over 6 hours increases the risk of bacterial growth and hemolysis in the blood unit, as transfusions should typically be completed within 4 hours. Prolonged infusion does not prevent reactions and may cause complications, making it an incorrect action for ensuring safe transfusion practices.

Choice A reason: Esophageal varices are a major complication of cirrhosis and portal hypertension. Increased portal vein pressure from liver scarring causes collateral vessel formation, including varices in the esophagus. These fragile vessels can rupture, leading to life-threatening gastrointestinal bleeding, requiring urgent monitoring and interventions like band ligation or beta-blockers to reduce risk.

Choice B reason: Pulmonary edema is not directly associated with cirrhosis or portal hypertension. It occurs in heart failure or fluid overload, which may be secondary to other conditions but not a primary complication of liver disease. Cirrhosis complications focus on portal system effects, like varices, rather than pulmonary fluid accumulation.

Choice C reason: Hypoglycemia may occur in end-stage cirrhosis due to impaired gluconeogenesis in the liver, but it is not the primary complication of portal hypertension. Esophageal varices pose a more immediate, life-threatening risk due to potential massive bleeding, making them a higher monitoring priority than metabolic disturbances like hypoglycemia.

Choice D reason: Hypernatremia is not a common complication of cirrhosis or portal hypertension. Cirrhosis may lead to hyponatremia due to impaired water excretion and fluid retention from low albumin and aldosterone dysregulation. Monitoring for varices is more critical, as they pose a direct risk of catastrophic bleeding compared to electrolyte imbalances.