The nurse is reviewing the client's medical record.

The nurse is assisting with the care the client prior to a blood transfusion

Which of the following actions should the nurse take? Select all that apply.

A) Decreased hemoglobin level: A decreased hemoglobin level is not an expected or desirable outcome of taking furosemide. While furosemide can cause fluid loss, it does not directly affect red blood cell production or hemoglobin levels. A decrease in hemoglobin could indicate anemia or another underlying issue, which should be addressed separately.

B) Increased weight of 0.91 kg (2 lb): An increase in weight, especially in a client with heart failure, could indicate fluid retention rather than effective diuresis. Furosemide is a diuretic that helps reduce fluid buildup, so an increase in weight would typically suggest that the medication is not effectively managing fluid overload, which is a key issue in heart failure.

C) Increased urinary output: An increase in urinary output is a clear indicator that furosemide is working effectively. Furosemide is a loop diuretic, which promotes the excretion of sodium and water, leading to increased urine output. This helps reduce fluid volume in the body, which is beneficial for a client with heart failure.

D) Decreased BUN level: While furosemide can affect kidney function, a decrease in blood urea nitrogen (BUN) level is not a direct indicator of the medication’s effectiveness. BUN can be influenced by various factors such as hydration status, kidney function, and protein intake. A decreased BUN level does not directly correlate with furosemide's effectiveness in treating heart failure.

A) Allow the client to have 1 hour of time alone in their room:
Allowing the client to be alone in their room may not be the best option when they are pacing and wringing their hands, which may indicate anxiety or distress. Rather than isolating them, it is more appropriate to offer support and engage with the client to address the potential underlying anxiety or agitation. Time alone may escalate the feelings of distress rather than provide relief.

B) Use short, simple sentences when speaking with the client:
Using short, simple sentences is an appropriate action when interacting with a client who is pacing and wringing their hands, as this behavior can be indicative of heightened anxiety or agitation. Simple communication reduces confusion and minimizes the cognitive load on the client, helping to keep the interaction clear and calm. It can also help the nurse better assess the client’s feelings and needs in a way that feels less overwhelming to the client.

C) Ask the client if they would like to watch television:
While offering the option of watching television could be an attempt to distract or comfort the client, it does not directly address the potential underlying anxiety or distress the client may be experiencing. It is important to first assess and manage the client’s emotional state before offering distractions like television, which may not effectively address the root of the issue.

D) Move the client to a table where other clients are playing cards:
Moving the client to a group activity may not be the best approach in this situation. The client is demonstrating signs of anxiety or agitation, and suddenly introducing them to a group environment might be overwhelming and could increase their distress. It is more appropriate to first engage the client in a calm, one-on-one interaction using simple communication, and then consider group activities if the client appears ready for them.