The nurse reviews the entries in the medical record. Exhibits The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Nursing Action Indicated Not Indicated Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mmHg ✅ Stay with the client for the first 15 minutes of the transfusion ✅ Start an IV bolus of lactated Ringer’s solution ✅ Obtain the first unit of packed RBCs from the blood bank ✅ Document the blood product transfusion in the client’s medical records ✅ Rationale: Indicated: Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mmHg: - The client is hypotensive (76/45 mmHg), likely due to acute blood loss anemia from a gastrointestinal (GI) bleed. Adjusting the transfusion rate helps stabilize BP while preventing volume overload. Stay with the client for the first 15 minutes of the transfusion: The highest risk of a transfusion reaction (e.g., hemolysis, anaphylaxis, febrile reaction) occurs within the first 15 minutes, so the nurse must remain with the client for close monitoring. Obtain the first unit of packed RBCs from the blood bank: The client’s condition (hypotension, tachycardia, history of melena) suggests GI bleeding and significant blood loss. RBC transfusion is required to restore oxygen-carrying capacity and improve perfusion. Document the blood product transfusion in the client’s medical records: Proper documentation includes blood product type, volume infused, time started and completed, client response, and any adverse reactions. This ensures compliance with safety protocols. Not Indicated: Start an IV bolus of lactated Ringer’s solution: Lactated Ringer’s (LR) is incompatible with blood products because it contains calcium, which can cause clotting in the IV line. Normal saline (0.9% NaCl) should be used instead.