A charge nurse is precepting a newly licensed nurse who is to administer a transfusion of packed red blood cells (PRBC) to a client who has anemia. Which of the following actions by the new nurse should cause the charge nurse to intervene in this client's care immediately?
The nurse stays with the client for 15 minutes after beginning the transfusion.
The nurse primes the blood tubing with lactated ringers.
The nurse starts the infusion at a slow rate for the first 15 minutes.
The nurse witnesses the client sign the consent form for the blood transfusion.
The Correct Answer is B
A. The nurse stays with the client for 15 minutes after beginning the transfusion:
This action is appropriate as it ensures the nurse monitors the client closely for any immediate adverse reactions during the initial phase of the transfusion.
B. The nurse primes the blood tubing with lactated Ringer's solution:
This action is incorrect and potentially dangerous. Blood tubing should be primed with normal saline (0.9% sodium chloride) solution, not lactated Ringer's solution, to prevent potential adverse reactions or hemolysis of the blood products.
C. The nurse starts the infusion at a slow rate for the first 15 minutes:
This action is appropriate as it allows for the initial assessment of the client's tolerance to the transfusion and reduces the risk of adverse reactions.
D. The nurse witnesses the client sign the consent form for the blood transfusion:
This action is appropriate and ensures that the client has provided informed consent for the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
To calculate the volume of heparin to administer subcutaneously, you can use the following formula:
Volume (mL) = Desired dose (units) / Concentration (units/mL)
In this case:
Desired dose = 3,800 units
Concentration = 5,000 units/mL
Volume (mL) = 3,800 units / 5,000 units/mL ≈ 0.76 mL
Rounded to the nearest tenth, the nurse should administer approximately 0.8 mL of heparin subcutaneously daily.
Correct Answer is B
Explanation
A. Notify the blood bank of the discrepancy:
This choice suggests that there is a discrepancy between the blood type of the unit on hand (type B) and the client's blood type (type AB). However, in reality, there is no discrepancy in this case because individuals with type AB blood are universal recipients and can receive blood from donors of any blood type, including type B. Therefore, there is no need to notify the blood bank of any discrepancy.
B. Administer the blood as ordered:
This choice is the correct action. Type AB individuals are known as universal recipients because they can safely receive blood from donors of any blood type (A, B, AB, or O) without causing a major transfusion reaction. Since the client has type AB blood and the unit of blood on hand is type B, the nurse can administer the blood as ordered without concerns about blood type compatibility.
C. Complete an incident report:
Completing an incident report is typically done when an unexpected event or error occurs during patient care. In this scenario, there is no error or unexpected event related to blood type compatibility, so there is no need to complete an incident report.
D. Contact the provider for further orders:
Contacting the provider for further orders would be necessary if there were a specific reason or concern related to the blood transfusion that requires clarification or additional instructions. However, in this case, there are no issues with blood type compatibility, so contacting the provider is not necessary.
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