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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Related Questions
Correct Answer is D
Explanation
Choice A reason: This is an incorrect intervention, because ambulating the client every 1 hr can increase the oxygen demand and worsen the sickling of the red blood cells.
Choice B reason: This is an incorrect intervention, because applying cold compresses to painful joints can cause vasoconstriction and reduce the blood flow to the affected areas.
Choice C reason: This is an incorrect intervention, because withholding opioids until the crisis is resolved can cause unnecessary suffering and increase the stress response, which can trigger more sickling.
Choice D reason: This is the correct intervention, because administering oxygen via nasal cannula can improve the oxygen saturation and prevent further sickling of the red blood cells.
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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