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 C

Explanation

A. "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination.": This response is premature as it assumes a diagnosis of hypertension based on a single elevated blood pressure reading without further assessment or confirmation.

B. "We will need to reevaluate your blood pressure because age places you at high risk for hypertension.": While age is a risk factor for hypertension, it is important not to jump to conclusions based on one blood pressure reading. Reevaluation and monitoring are necessary before making any definitive diagnoses or treatment decisions.

C. "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.": This response is appropriate because it acknowledges the need for further assessment and monitoring before determining if the client has hypertension. It also educates the client about the importance of multiple readings for an accurate diagnosis.

D. "You have no need to worry. Your pressure is probably elevated because you are being tested.": This response dismisses the client's concerns and does not provide accurate information about blood pressure assessment and hypertension diagnosis.

A. The test is noninvasive, and nothing will be inserted into the client's body. B. The client will remain on bed rest for 1 to 2 hours after the test. C. The client's pain will be managed aggressively during the procedure. D. The test will provide a detailed profile of the heart's electrical activity.

Correct Answer is A

Explanation

A. The test is noninvasive, and nothing will be inserted into the client's body: Transthoracic echocardiography (TTE) is a noninvasive procedure that uses ultrasound waves to create images of the heart. It involves placing a transducer on the chest wall to capture images of the heart's structure and function. The nurse should inform the client that no instruments or devices will be inserted into their body during the test.

B. The client will remain on bed rest for 1 to 2 hours after the test: This statement is not typically accurate for a TTE procedure. After a TTE, clients can usually resume their normal activities without any specific bed rest requirements, unless otherwise specified by the healthcare provider based on individual circumstances.

C. The client's pain will be managed aggressively during the procedure: TTE is generally a painless procedure that does not require aggressive pain management. The client may feel slight discomfort from the transducer's pressure on the chest, but it is typically well tolerated without the need for pain medication.

D. The test will provide a detailed profile of the heart's electrical activity: While echocardiography provides detailed images of the heart's structure and function, including information about blood flow and valve function, it does not directly assess the heart's electrical activity. For evaluating electrical activity, other tests such as electrocardiography (ECG or EKG) would be used.

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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

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Correct Answer is C

Explanation

A client is scheduled for a transthoracic echocardiography (TTE). What should the nurse teach the client in anticipation of this diagnostic procedure?

Correct Answer is A

Explanation

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