A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

Check and document the client's vital signs

Ensure that the client's IV site uses a 22-gauge needle

Verify that the blood type and Rh of the packed RBCs are checked by two nurses

Obtain a bag of lactated Ringer's IV solution

Provide the RN with tubing that has a filter

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Checking and documenting the client's vital signs is a correct action, because it provides a baseline for comparison and helps to monitor for any signs of adverse reactions to the transfusion.

Choice B reason: Ensuring that the client's IV site uses a 22-gauge needle is an incorrect action, because a larger gauge needle (18- or 20-gauge) is preferred for blood transfusions to prevent hemolysis of the RBCs.

Choice C reason: Verifying that the blood type and Rh of the packed RBCs are checked by two nurses is a correct action, because it is a standard safety procedure to prevent transfusion errors and ensure compatibility.

Choice D reason: Obtaining a bag of lactated Ringer's IV solution is an incorrect action, because only normal saline (0.9% sodium chloride) should be used as the IV solution for blood transfusions. Other solutions may cause hemolysis or clotting of the blood.

Choice E reason: Providing the RN with tubing that has a filter is a correct action, because a filter is required for blood transfusions to remove any clumps or debris from the blood.

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Correct Answer is D

Explanation

Choice A reason: This is a correct statement, because the stool consistency depends on the location of the colostomy. A sigmoid colostomy is located in the lower part of the colon, where most of the water is absorbed, so the stool will be formed.

Choice B reason: This is a correct statement, because the stoma size will decrease as the swelling subsides and the wound heals. The stoma will reach its final size in about 6 to 8 weeks after surgery.

Choice C reason: This is a correct statement, because the colostomy function will resume gradually after surgery, depending on the bowel motility and the presence of gas or stool. The colostomy will usually start to function 2 to 6 days after surgery.

Choice D reason: This is an incorrect statement, because the diet does not have to change to a soft diet after surgery. The client can resume a normal diet as tolerated, unless there are specific dietary restrictions or recommendations from the provider. A soft diet may be recommended only for the first few days after surgery, to avoid bowel obstruction or irritation.

A. A client who has benign prostate hyperplasia (BPH) and reports dysuria B. A client who has ulcerative colitis and reports diarrhea C. A client who has emphysema and reports dyspnea D. A client who has esophageal cancer and reports painful swallowing

Correct Answer is C

Explanation

Choice A reason: A client who has BPH and reports dysuria is not the highest priority, because dysuria is a common symptom of BPH and does not indicate an acute complication. The nurse should monitor the client's urinary output and provide comfort measures.

Choice B reason: A client who has ulcerative colitis and reports diarrhea is not the highest priority, because diarrhea is a chronic symptom of ulcerative colitis and does not indicate an acute complication. The nurse should assess the client's hydration status and electrolyte levels and administer medications as prescribed.

Choice C reason: A client who has emphysema and reports dyspnea is the highest priority, because dyspnea is a sign of respiratory distress and can indicate an acute exacerbation of emphysema. The nurse should assess the client's oxygen saturation and respiratory rate and administer oxygen therapy as prescribed.

Choice D reason: A client who has esophageal cancer and reports painful swallowing is not the highest priority, because painful swallowing is a common symptom of esophageal cancer and does not indicate an acute complication. The nurse should provide the client with soft or liquid foods and administer analgesics as prescribed.

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A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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