A nurse is assisting in the care of a client who is to receive a transfusion of packed red blood cells (PRBCs). Which of the following solutions should be administered with PRBCs?
0.9% sodium chloride
Dextrose 5% in water
Lactated Ringer's
Dextrose 5% in 0.45% sodium chloride
The Correct Answer is A
Choice A reason: 0.9% sodium chloride or normal saline is the only solution that should be administered with PRBCs, as it has an isotonic osmolarity and pH that are compatible with blood products and can prevent hemolysis or clotting.
Choice B reason: Dextrose 5% in water or D5W should not be administered with PRBCs, as it has a hypotonic osmolarity that can cause hemolysis or rupture of red blood cells due to osmotic pressure.
Choice C reason: Lactated Ringer's or LR should not be administered with PRBCs, as it contains calcium and lactate that can interfere with blood coagulation and cause clotting or embolism.
Choice D reason: Dextrose 5% in 0.45% sodium chloride or D5½NS should not be administered with PRBCs, as it has a hypotonic osmolarity that can cause hemolysis or rupture of red blood cells due to osmotic pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: This is incorrect because applying petroleum jelly to the client's nares can interfere with oxygen delivery and cause skin breakdown. The nurse should use water-soluble lubricant or saline spray to moisten the nares and prevent dryness from oxygen therapy.
Choice B: This is correct because initiating fall precautions can prevent injury and complications for the client who has aspirated pneumonia and hypoxia. The client may have altered mental status, weakness, or dizziness due to hypoxia, infection, or medications. The nurse should use bed alarms, side rails, and assistive devices as needed.
Choice C: This is incorrect because maintaining the client in a supine position can worsen hypoxia and pneumonia by decreasing lung expansion and increasing secretions. The nurse should elevate the head of the bed at least 30 degrees and encourage frequent position changes to improve ventilation and drainage.
Choice D: This is incorrect because implementing contact precautions is not indicated for the client who has aspirated pneumonia and hypoxia. Aspirated pneumonia is caused by inhalation of foreign material into the lungs, not by transmission of microorganisms from person to person. The nurse should use standard precautions and droplet precautions if the client has a cough or sputum production.
Correct Answer is A
Explanation
Choice a: Placing the client in high-Fowler's position is the first action that the nurse should take because it can improve lung expansion and oxygenation, which are priority needs for a client who has a pulmonary embolism and is experiencing dyspnea.
Choice b is not correct because administering heparin to the client is not the first action that the nurse should take, but rather a subsequent action after ensuring adequate oxygenation. Heparin can prevent further clot formation and reduce the risk of complications, but it does not dissolve existing clots or improve respiratory status.
Choice c is not correct because encouraging the client to cough and deep breathe is not the first action that the nurse should take, but rather an ongoing intervention that can help mobilize secretions and prevent atelectasis. However, it may not be effective or feasible for a client who has severe dyspnea.
Choice d is not correct because obtaining the client's vital signs is not the first action that the nurse should take, but rather an assessment that can provide baseline data and monitor changes in condition. However, it does not address the immediate problem of impaired gas exchange or relieve dyspnea.
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