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 A

Explanation

Choice A reason: This is the correct action, because weighing the client before and after each dialysis treatment can help monitor the fluid balance and the effectiveness of the dialysis.

Choice B reason: This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.

Choice C reason: This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.

Choice D reason: This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.

A. Estimation of burn injury B. Respiratory rate C. Presence of bowel sounds D. Level of pain

Correct Answer is B

Explanation

Choice A reason: This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.

Choice B reason: This is the correct data, because the nurse should first collect the respiratory rate to determine if the client has any signs of airway obstruction, inhalation injury, or respiratory distress, which are life-threatening complications of facial burns.

Choice C reason: This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.

Choice D reason: This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.

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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

A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?

Correct Answer is B

Explanation

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