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 D
Explanation
A. Furosemide 10mg IV bolus every 12 hours:
Furosemide is a loop diuretic commonly used in heart failure management to reduce fluid overload. The prescribed dose of 10 mg IV bolus every 12 hours is within the typical range for furosemide administration in acute heart failure.
B. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain:
Morphine sulfate is often used in the management of acute pain, including pain associated with myocardial infarction. The prescribed dose of 2 mg IV bolus every 2 hours PRN for pain is appropriate and aligns with standard pain management protocols.
C. Laboratory testing of serum potassium upon admission:
It is common practice to perform laboratory testing, including serum potassium levels, upon admission for clients with acute heart failure, especially if they are receiving diuretics or other medications that can affect electrolyte balance. This prescription is appropriate and necessary for monitoring the client's condition.
D. 0.9% normal saline IV at 150 mL/hr continuous:
This prescription raises a concern because administering 0.9% normal saline at a rate of 150 mL/hr continuously may lead to fluid overload in a client with acute heart failure. The rate of IV fluid administration should be carefully assessed based on the client's fluid status, renal function, and hemodynamic parameters to avoid exacerbating heart failure symptoms.
Correct Answer is D
Explanation
A. "Hypertension is the leading cause of death in people your age.": While hypertension is a significant risk factor for cardiovascular events and mortality, stating it as the leading cause of death without specific context or statistical data may not provide the most informative response to the client's question.
B. "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group.": Hypertension is primarily associated with cardiovascular risks such as stroke, heart disease, and kidney disease. While it can contribute to overall health risks, it is not typically linked directly to type 1 diabetes or cancer in the context of this client's question.
C. "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs.": While hypertension can contribute to cardiovascular complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE), these are not the primary risks that are typically emphasized when discussing the importance of treating hypertension.
D. "Hypertension greatly increases your risk of stroke and heart disease.": This response is the most relevant and specific to the client's question. Hypertension is a major risk factor for stroke, heart disease (including heart attack and heart failure), and other cardiovascular complications. By treating hypertension and controlling blood pressure within recommended targets, the client can significantly reduce the risk of these serious and potentially life-threatening conditions.
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