The Nurse Is Providing Care for a Client Who Is

question 4

Multiple Choice

The nurse is providing care for a client who is receiving a blood transfusion.Pre-transfusion vital signs were blood pressure (BP) , 144/78 mm Hg; temperature (T) , 98.4°F; pulse (P) , 86; respirations (R) , 14.Now, approximately an hour after the transfusion was initiated, the client's vital signs are BP, 168/92 mm Hg; P, 98; R, 20.Next, the nurse should:

• A)Record the vital signs.
• B)Listen to the client's breath sounds.
• C)Notify the physician.
• D)Slow the transfusion rate.

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Definitions:

Clarification

The process of making a statement or situation less confused and more comprehensible.

Restraining Force

Factors or conditions that resist or oppose the progress, change, or movement within an organization or system.

Driving Force

An element or factor that propels or motivates individuals or groups towards a particular direction or goal.

Restrictive Force

Factors or influences that limit capabilities, freedoms, or the scope of action.