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 C
Explanation
A. "I will not have to get an IV placed."An IV may be placed in some cases, especially if the stress test includes the use of a pharmacological agent (like adenosine or dobutamine) in place of exercise.
B. "I can eat my breakfast before the test."Clients are typically instructed to fast for at least 3 hours before the exercise stress test. Eating could interfere with accurate test results and the ability to safely exercise. The client should not eat right before the test.
C. "I must not drink my hot chocolate in the morning."Caffeine can interfere with the results of the exercise stress test by increasing heart rate and potentially masking abnormal responses to exercise. Therefore, the client should avoid caffeine (including hot chocolate) before the test.
D. "I can wear the clothes I would wear to the office."The client should wear comfortable clothing and shoes that allow for physical activity and movement, such as athletic wear. Office attire may not be suitable for the physical exertion required during the exercise stress test.
Correct Answer is ["125"]
Explanation
To calculate the infusion rate in mL/hr, you can use the formula:
Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)
In this case, the total volume is 1000 mL and the total time is 8 hours.
Infusion rate = 1000 mL / 8 hr
Infusion rate ≈ 125 mL/hr
The nurse should set the IV pump to deliver approximately 125 mL/hr.
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