The nurse is reviewing vaccination records for several clients in a long-term care facility. Which client should the nurse identify as needing immunization education or intervention?

A.Epinephrine is the primary treatment for an anaphylactic reaction, but it should only be administered after the nurse has stopped the offending agent and assessed the patient. Administering it before stopping the transfusion would allow more potentially incompatible blood to enter the patient's circulation. The nurse must follow the sequence of the nursing process, beginning with the immediate removal of the cause of the reaction.

B.Assessing vital signs is a necessary step in the evaluation of a transfusion reaction, but it must occur after the infusion has been stopped. Chills and a headache are early indicators of potentially severe reactions, such as an acute hemolytic or febrile non-hemolytic reaction. Delaying the cessation of the transfusion to take a blood pressure reading increases the total volume of incompatible blood the patient receives.

C.The first and most critical action when any transfusion reaction is suspected is to stop the transfusion immediately to minimize the exposure to the blood product. This prevents further entry of antigens or incompatible cells into the patient's bloodstream, which could escalate the severity of the immune response. Once the line is stopped and disconnected, the nurse can then proceed to provide supportive care and further assessment.

D.Notifying the provider is a required step in the management of a transfusion reaction, but it is not the first priority. The nurse must first ensure the patient's safety by stopping the blood and assessing their current clinical status to provide an accurate report to the provider. Timely communication is essential for obtaining new orders, but it never supersedes the immediate action of stopping a dangerous infusion.

A.Severe hypokalemia significantly alters the resting membrane potential of myocardial cells, increasing the risk of lethal ventricular dysrhythmias. Continuous electrocardiographic monitoring is essential during intravenous replacement to detect premature ventricular contractions or heart block. This allows the nurse to intervene immediately if the infusion rate causes rapid shifts in cardiac electrical conduction.

B.Furosemide is a loop diuretic that causes significant renal potassium wasting by inhibiting the sodium-potassium-chloride cotransporter. Providing education on potassium-rich dietary sources helps the client maintain electrolyte homeostasis and prevents future episodes of profound deficiency. Nutritional management is a key component of long-term therapy for patients requiring chronic diuretic use for fluid volume management.

C.Drawing serum potassium levels immediately after an infusion provides an inaccurate reflection of the total body potassium stores due to incomplete equilibration. Potassium is primarily an intracellular cation, and premature testing only measures the transiently high intravascular concentration. Protocols typically require waiting several hours after the infusion ends to ensure the laboratory results reflect a true systemic steady state.

D.Preparing potassium infusions solely with 5% dextrose can be counterproductive because glucose stimulates insulin release, which shifts potassium from the extracellular fluid into the cells. This intracellular shift can actually lower the serum potassium level further during the initial phase of administration. Saline-based solutions are often preferred to ensure that the administered potassium remains in the vascular space to correct the deficit.

E.Potassium is primarily excreted by the kidneys, and administration in the presence of oliguria or renal failure can lead to rapid, life-threatening hyperkalemia. Verifying adequate renal function, defined as an output of at least 0.5 to 1 mL/kg/hour, ensures the body can safely process and excrete the supplemental mineral. This nursing action is a critical safety barrier against the development of iatrogenic potassium toxicity.