The practical nurse (PN) is caring for a client with pyelonephritis who is admitted for parenteral anti-infective therapy. Prior to discharge home with an oral medication regimen, which instruction is most important for the practical nurse (PN) to reinforce with the client?

Choice A reason: Administering a PRN prescription for an antiemetic might help with the nausea and vomiting, but it is not the first action to take. The primary concern should be addressing a potential transfusion reaction.
Choice B reason: Flushing the IV tubing with sodium chloride is an important step to clear the line of any remaining blood product, but this should be done after stopping the infusion to prevent further administration of the blood.
Choice C reason: Notifying the healthcare provider is crucial, but the first and most immediate action should be to stop the blood infusion to prevent further reaction.
Choice D reason: Turning off the blood infusion is the first and most critical action to take. Shaking, nausea, and vomiting can be signs of a transfusion reaction, and halting the infusion immediately helps prevent further complications. Following this, the nurse should notify the healthcare provider and take other appropriate measures.

Choice A reason: Assessing the mucous membranes can provide useful information about the client’s overall hydration status. Checking for signs of dehydration, such as dry or sticky mucous membranes, can indicate whether the client may need additional fluids or intervention. However, this assessment does not directly address the issue of decreased urine output in the catheter, which might be due to a blockage or mechanical issue with the catheter itself.
Choice B reason: Ensuring that the catheter tubing is straight is crucial because any kinks or bends in the tubing can obstruct the flow of urine, leading to decreased urine output. This is a simple yet essential step that can be quickly performed by the practical nurse to rule out mechanical obstruction as the cause of the problem. By straightening the tubing, the nurse can help restore proper urine flow without the need for further invasive interventions.
Choice C reason: Auscultating lung sounds is an important assessment to determine if the client has any respiratory complications, such as fluid overload or pneumonia, which can sometimes occur post-transplant. While this is a critical assessment for overall health, it does not directly address the immediate issue of decreased urine output in the catheter. It is important to prioritize assessments that are directly related to the symptom being observed.
Choice D reason: Determining the dryness of bed linens can help assess if there has been any urine leakage around the catheter site or if the catheter is not functioning properly. Wet bed linens might indicate that the urine is bypassing the catheter or that there is a leak in the system. However, this assessment alone may not provide enough information to address the decreased urine output and should be combined with other assessments like ensuring the catheter tubing is straight.
Choice E reason: Irrigating the catheter to assess patency is a direct and immediate action that can help identify if the catheter is blocked. If there is resistance during irrigation, it indicates that the catheter may be obstructed, and further action is required to clear the blockage. This assessment can help resolve the issue of decreased urine output and is a practical step before notifying the charge nurse, as it provides a clear indication of the catheter's functionality.