The nurse is staying with a patient who has been started on a blood transfusion. Which assessment should the nurse perform during a blood product infusion to detect a reaction?

Correct Answer: A

Rationale: Correct Answer: A (Vital signs) Rationale: Monitoring vital signs during a blood transfusion is crucial to detect any adverse reactions promptly. Changes in blood pressure, pulse rate, temperature, and respiratory rate can indicate a potential reaction. By assessing vital signs, the nurse can intervene promptly if there is any sign of an adverse reaction, such as fever, hypotension, tachycardia, or shortness of breath. Summary of Incorrect Choices: B: Skin turgor is not directly related to detecting a reaction during a blood transfusion. C: Bowel sounds are not indicative of a reaction during a blood transfusion. D: Pupil reactivity is not relevant for monitoring during a blood transfusion.

Correct Answer: C

Rationale: The correct answer is C (1.5 to 2.0 times normal) because the therapeutic range for heparin therapy is typically considered to be 1.5 to 2.0 times the normal control value for activated partial thromboplastin time (aPTT). This range ensures adequate anticoagulation to prevent clot formation without increasing the risk of bleeding. Options A, B, and D are incorrect because they provide ranges that are either too short or too long for the therapeutic goal of heparin therapy. Option A (2.5 to 9.5 minutes) and Option D (2.0 to 3.0 times normal) are outside the typical therapeutic range for heparin, indicating subtherapeutic and supratherapeutic levels, respectively. Option B (9.5 to 11.3 seconds) is also incorrect as it reflects a range for prothrombin time (PT) rather than aPTT.

Correct Answer: A

Rationale: The correct answer is A: Do you take salicylates? Petechiae can be a sign of salicylate use, which can cause bleeding disorders. By asking about salicylates, the nurse can determine if the petechiae are related to medication. Choice B is not directly related to petechiae. Choice C is more specific to antiseizure drugs and not commonly associated with petechiae. Choice D is unrelated to petechiae and focuses on hypertension management. Asking about salicylates is the most appropriate to assess potential medication-induced petechiae.

Correct Answer: D

Rationale: The correct answer is D: Hemoglobin (Hgb) level. Pallor of the skin and nail beds indicates possible anemia, which is a condition characterized by low levels of hemoglobin. Thus, checking the hemoglobin level is crucial to confirm the suspicion of anemia. Platelet count (choice A) assesses for clotting ability, neutrophil count (choice B) and white blood cell count (choice C) are indicators of infection or inflammation, which are not directly related to pallor. Hemoglobin level directly correlates with the observed symptom of pallor, making it the most appropriate laboratory test to order.

Correct Answer: D

Rationale: The correct answer is D: Place the client on safety precautions. A platelet count of 58,000/mm³ indicates thrombocytopenia, increasing the risk of bleeding. Safety precautions aim to prevent injury and minimize bleeding risks. Encouraging high-protein foods (choice A) is not directly related to managing thrombocytopenia. Instituting neutropenic precautions (choice B) is for clients with low white blood cell counts, not platelet counts. Limiting visitors to healthy adults (choice C) is important for infection control, not specifically for thrombocytopenia. In summary, placing the client on safety precautions is the best action to prevent bleeding complications.