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. "I have a difficult time falling asleep at night":

Difficulty falling asleep at night is not typically a direct symptom of iron-deficiency anemia. While anemia can lead to fatigue and general tiredness, which might affect sleep quality, insomnia or difficulty falling asleep may have various causes unrelated to anemia. These causes can include stress, anxiety, poor sleep hygiene, or other underlying medical conditions.

B. "I have an increase in my appetite":

This choice is not directly related to iron-deficiency anemia. While some individuals with anemia may experience changes in appetite, such as increased hunger, this symptom is not specific to iron-deficiency anemia alone. An increase in appetite can have various causes, including hormonal changes, dietary changes, medications, or psychological factors.

C. "I have difficulty breathing when walking 30 feet":

This choice is the correct answer. Difficulty breathing, especially during exertion like walking, is a hallmark symptom of iron-deficiency anemia. Anemia reduces the oxygen-carrying capacity of the blood, leading to inadequate oxygen delivery to tissues, which can result in shortness of breath, fatigue, and difficulty with physical activities.

D. "I feel hot all of the time":

Feeling hot all the time is not a specific symptom of iron-deficiency anemia. While anemia can cause symptoms such as fatigue, weakness, pale skin, and shortness of breath, it does not directly lead to a constant feeling of heat or warmth throughout the body. Feeling hot or experiencing excessive sweating could be due to other factors such as hormonal changes, fever, hyperthyroidism, or environmental conditions.

A. numbness in extremities B. fatigue C. Shortness of breath D. anorexia E. Chest pain F. Confusion

Correct Answer is ["B","C","D","E","F"]

Explanation

A. Numbness in extremities: Numbness in extremities is not a common adverse effect of digoxin. The focus of digoxin monitoring is primarily on cardiovascular and gastrointestinal effects.

B. Fatigue: Fatigue is a common adverse effect of digoxin and can indicate toxicity or overdose. Clients taking digoxin should be monitored for increased fatigue or weakness.

C. Shortness of breath: Shortness of breath can occur as an adverse effect of digoxin toxicity, particularly if it leads to pulmonary congestion or heart failure exacerbation.

D. Anorexia: Anorexia, or loss of appetite, can be a gastrointestinal adverse effect of digoxin. Clients may experience nausea, vomiting, or anorexia, which can contribute to weight loss and electrolyte imbalances.

E. Chest pain: Chest pain can be a sign of digoxin toxicity, especially if it is associated with other symptoms such as shortness of breath or palpitations. It is essential to evaluate any chest pain in a client taking digoxin.

F. Confusion: Confusion or changes in mental status can occur with digoxin toxicity, particularly in older adults. Clients should be monitored for signs of confusion, delirium, or other cognitive changes.

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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

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

Correct Answer is C

Explanation

The nurse is caring for a client prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? (Select All that Apply.)

Correct Answer is ["B","C","D","E","F"]

Explanation

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