The nurse is caring for a client with acute pancreatitis.
What meal choice is best for this client's first meal after being NPO for 48 hours?

Choice A rationale

Multiple sclerosis is a chronic demyelinating disease where nerve fibers in the central nervous system lose their protective coating. Exposure to high temperatures, such as hot baths, can cause a temporary worsening of neurological symptoms, a phenomenon known as Uhthoff's sign. Heat slows the conduction of nerve impulses through already damaged axons. Clients should use lukewarm water to avoid exacerbating fatigue, muscle weakness, or visual disturbances that occur with increased body temperature.

Choice B rationale

Fatigue is one of the most common and debilitating symptoms of multiple sclerosis, often described as an overwhelming sense of exhaustion. Scheduling regular rest periods helps the client manage their energy levels and prevents the physical overexertion that can trigger a flare or worsen existing symptoms. This strategy promotes a balance between activity and recovery, allowing the client to maintain a higher quality of life and better functional independence in their daily activities.

Choice C rationale

Diplopia, or double vision, occurs in multiple sclerosis due to lesions in the brainstem or cranial nerves that coordinate eye movements. Wearing an eye patch over one eye is a common compensatory strategy to eliminate the confusing second image, thereby improving safety and reducing dizziness or nausea associated with visual distortion. This statement indicates the client understands how to manage sensory symptoms effectively and safely during a period of active neurological dysfunction or relapse.

Choice D rationale

While heat is a more common trigger, extreme cold or sudden temperature changes can also exacerbate symptoms like muscle spasticity or sensory disturbances in multiple sclerosis. Cold environments may cause muscles to tighten or result in increased pain and discomfort for the client. Avoiding getting chilled helps maintain a stable internal environment, which is beneficial for nerve conduction and muscle relaxation. This shows the client is aware of environmental factors that impact their condition.

Choice A rationale

Calling the healthcare provider is a necessary step once the transfusion has been stopped and the client is stabilized. The provider needs to be informed of the adverse reaction to order appropriate medications, such as antipyretics, antihistamines, or corticosteroids, and to determine the next steps for the client's care. Timely notification ensures that the medical team can manage potential complications like acute hemolytic reactions or febrile non-hemolytic transfusion reactions effectively.

Choice B rationale

Stopping the transfusion is the immediate priority action when any sign of a transfusion reaction occurs, such as chills, headache, or a temperature increase. Normal temperature is approximately 98.6 F, and the client's rise to 100.9 F indicates a significant febrile response. Discontinuing the blood flow prevents further exposure to the potentially incompatible or contaminated product, which is essential to protect the client from worsening symptoms or life-threatening systemic complications.

Choice C rationale

Monitoring vital signs is critical to assess the client's hemodynamic stability and the progression of the reaction. The client is currently tachycardic with a heart rate of 106 beats per minute and tachypneic with 22 breaths per minute. Continuous assessment of blood pressure, heart rate, and temperature allows the nurse to detect signs of shock or escalating systemic inflammation early, providing vital data for the healthcare provider to guide subsequent emergency treatments.

Choice D rationale

Returning all tubing and blood products to the blood bank is a standard protocol for investigating transfusion reactions. The laboratory must perform a clerical check and various tests, such as a direct antiglobulin test, to identify the cause of the reaction, such as ABO incompatibility or bacterial contamination. This process is vital for documenting the event, ensuring future transfusion safety, and determining if other blood units from the same donor are compromised.

Choice E rationale

Flushing the current IV tubing with 0.9 percent normal saline is contraindicated because it would push the remaining blood in the tubing into the client's circulation. If a reaction is suspected, the nurse should disconnect the blood tubing at the hub of the catheter and initiate a new infusion of normal saline using completely new tubing. This keeps the vein patent for emergency medications without further exposing the client to the reacting blood product.