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.

Answer and Explanation

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.

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Correct Answer is ["B","E"]

Explanation

A. Confirm that the room number matches the medical record.Room numbers should never be used as a sole method to identify a client. Room assignments can change, and relying on them could lead to errors.

B. Compare the client identification number to the blood component tag number.Matching the client identification number to the blood component tag ensures the blood is being administered to the correct client. This is a key step in preventing transfusion errors.

C. Verify the provider's prescription with another RN.While this is an important step in the blood administration process, it is not specifically related to identifying the client.

D. Ask the client to verbalize if the blood type is Rh-negative or positive.Clients may not know their blood type, and relying on their verbal confirmation is unsafe. The blood type must be confirmed through laboratory testing and matched with the blood being administered.

E. Scan the barcode on the client's identification band.Scanning the barcode on the client’s identification band is a reliable and commonly used method for verifying the client’s identity in modern healthcare settings. This ensures that the blood is administered to the correct client.

A. Ascending edema B. The client has no desire to eat. C. The client sleeps on three pillows at night. D. The client has a five pound weight gain.

Correct Answer is C

Explanation

A. Ascending edema:

Ascending edema, also known as dependent edema, is typically associated with right-sided heart failure rather than left-sided heart failure. In right-sided heart failure, the heart's ability to pump blood to the lungs for oxygenation is compromised, leading to fluid backup in the systemic circulation. This fluid accumulates in the dependent areas of the body, such as the lower extremities (legs and ankles), causing swelling that can ascend upwards if left untreated. However, ascending edema is not a characteristic finding in left-sided heart failure, where pulmonary congestion and orthopnea are more common manifestations.

B. The client has no desire to eat:

While decreased appetite can occur in heart failure due to various factors such as fluid retention, abdominal bloating, or medication side effects, it is not a specific hallmark of left-sided heart failure. Symptoms such as fatigue, dyspnea (shortness of breath), orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (PND) are more commonly associated with left-sided heart failure. These symptoms result from the impaired function of the left ventricle, leading to pulmonary congestion and inadequate oxygenation.

C. The client sleeps on three pillows at night:

This choice is the correct answer. Sleeping on three pillows at night is a classic manifestation of orthopnea, a condition commonly seen in left-sided heart failure. Orthopnea refers to difficulty breathing while lying flat, which is alleviated by elevating the head and upper body with multiple pillows or sleeping in a semi-upright position. Orthopnea occurs due to the redistribution of fluid from the legs and lower body to the lungs when lying down, resulting in pulmonary congestion and respiratory distress.

D. The client has a five-pound weight gain:

Weight gain is a common symptom of fluid retention in heart failure; however, a specific weight gain of five pounds alone may not be indicative of left-sided heart failure without considering other clinical signs and symptoms. In heart failure, weight gain is often associated with fluid overload, which can lead to edema, dyspnea, orthopnea, and other signs of congestion. It's important to assess the client comprehensively for fluid status, including evaluating for edema, respiratory symptoms, and changes in weight over time, to determine the underlying cause of weight gain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take to identify the client? (Select All that Apply.)

Correct Answer is ["B","E"]

Explanation

The nurse is assessing a client with left-sided heart failure. What would the nurse expect to find?

Correct Answer is C

Explanation

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