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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect finding, because Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Kussmaul respirations are deep and rapid breathing that help the body eliminate excess carbon dioxide and acid.
Choice B reason: This is the correct finding, because diaphoresis is a sign of hypoglycemia, which is a condition that occurs when the blood glucose is too low. Diaphoresis is excessive sweating that results from the activation of the sympathetic nervous system and the release of epinephrine, which stimulate the body to increase the blood glucose level.
Choice C reason: This is an incorrect finding, because decreased skin turgor is a sign of dehydration, which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Decreased skin turgor is a loss of elasticity and firmness of the skin that results from the loss of fluid and electrolytes through the urine and the skin.
Choice D reason: This is an incorrect finding, because ketonuria is a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Ketonuria is the presence of ketones in the urine, which are acidic substances that are produced when the body breaks down fat for energy due to the lack of insulin.
Correct Answer is C
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should obtain the prescribed irrigation solution after assessing the client's pain level and providing analgesia if needed.
Choice B reason: This is an important action, but not the first one. The nurse should don personal protective equipment after assessing the client's pain level and providing analgesia if needed.
Choice C reason: This is the correct action, because checking the client's pain level is the first step in the wound care process. The nurse should assess the client's pain level using a valid and reliable pain scale, and administer analgesia as prescribed before irrigating the wound.
Choice D reason: This is an important action, but not the first one. The nurse should place a waterproof pad under the client's extremity after assessing the client's pain level and providing analgesia if needed.
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