The nurse is assessing the client following the transfusion of 2 units of packed RBCs.

Exhibits

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Laboratory Results

1800

• WBC count 6700/mm3 15.000 to 10.000/mm
• Hemoglobin 12 g/dl (14 to 18 g/dL)
• Hematocrit 36% (40% to 52%)

Vital Signs

1800

• Blood pressure 112/74 mm Hg
• Heart rate 95/min
• Respiratory rate 18/
• Temperature 37.5°C (95°F)
• Oxygen saturation 100% via 2 L/min nasal cannula

 

Rationale:

A. Abdomen: The abdominal skin may be loose due to age-related changes, weight fluctuations, or prior pregnancies, making it less reliable for assessing dehydration in older adults. Lifting skin here may give a false impression of skin turgor.

B. Shoulder: Skin over the shoulder can be affected by aging, sun exposure, or decreased subcutaneous tissue, which can distort the assessment of hydration status. It is not the preferred site for older adults.

C. Neck: The skin of the neck is thin and may show wrinkles or sagging unrelated to hydration. Assessing turgor here is less accurate in older clients and may overestimate skin elasticity changes due to aging.

D. Sternum: The skin over the sternum is relatively less affected by age-related changes and provides a more reliable site for assessing turgor in older adults. Lifting this area allows the nurse to evaluate hydration status more accurately without interference from natural skin laxity elsewhere.

Rationale:

A. "I will avoid all alcohol while taking this medication.": Alcohol can increase the risk of bleeding while a client is on anticoagulants by affecting platelet function and liver metabolism of the drug. Avoiding alcohol reduces the likelihood of complications such as gastrointestinal bleeding or excessive bruising, making this an appropriate and effective understanding of anticoagulant safety.

B. "I will ask my provider before taking any supplements.": Many herbal supplements and over-the-counter medications can interact with anticoagulants, either increasing or decreasing their effect. Consulting the provider ensures the client avoids dangerous interactions that could lead to bleeding or clotting complications.

C. "I will call my provider if I have blood in my urine.": Hematuria may indicate significant bleeding while on anticoagulant therapy. Promptly reporting this symptom allows early intervention and prevents serious complications such as anemia or renal damage, showing that the client understands the need to monitor for adverse effects.

D. "I will plan to eat a green salad every day.": While leafy green vegetables are healthy, they are high in vitamin K, which can interfere with certain anticoagulants like warfarin. Regular high intake without provider guidance could reduce the medication’s effectiveness, so this statement reflects a misunderstanding rather than effective teaching.

E. "I will stop taking the anticoagulant if I get a nosebleed.": Stopping anticoagulants without provider instruction can increase the risk of thromboembolism. Minor bleeding like a nosebleed should be reported, not managed by abruptly discontinuing the medication, so this reflects unsafe practice.

F. "I will be careful to not cut myself.": Minimizing trauma and preventing cuts or injuries is essential while on anticoagulants because even minor injuries can lead to significant bleeding. This shows the client understands the practical precautions needed to stay safe during therapy.