A nurse is caring for a client at risk for fluid volume overload with an order to infuse 1 unit of blood. The health care provider specified the rate of infusion must be 8 hours to prevent the effects of fluid volume overload in this client. Which intervention should the nurse implement for this client?

Retrieve the blood from the laboratory and run each unit at an 8-hour rate.

Notify the laboratory to split the unit into 2, then infuse each half for 4 hours.

Call the HCP to question the order because blood must infuse within 4 hours.

Infuse each unit for 8 hours, the maximum rate for a unit of blood.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Retrieving the blood from the laboratory and running each unit at an 8-hour rate is not appropriate. According to transfusion guidelines, blood products should be infused within 4 hours to prevent bacterial growth and reduce the risk of transfusion-related complications1. Infusing blood over 8 hours increases the risk of these complications.

Choice B Reason:

Notifying the laboratory to split the unit into 2 and then infusing each half for 4 hours is also not ideal. While this approach might seem to address the time constraint, it is not a standard practice and could lead to issues with blood product integrity and patient safety2. Blood products are typically not split unless there are specific protocols in place, and this is not a common intervention for managing infusion rates.

Choice C Reason:

Calling the HCP to question the order is the correct intervention. Blood transfusions must be completed within 4 hours to ensure patient safety and maintain the integrity of the blood product3. The nurse should advocate for the patient by questioning any orders that do not align with established guidelines and best practices.

Choice D Reason:

Infusing each unit for 8 hours is incorrect. The maximum duration for infusing a unit of blood is 4 hours4. Extending the infusion time beyond this limit increases the risk of complications such as bacterial contamination and reduced efficacy of the blood product.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:

Keep the drainage system below the level of the client’s chest at all times is correct. This measure ensures that gravity assists in the drainage of air and fluid from the pleural space, preventing backflow into the chest cavity. Keeping the drainage system below chest level maintains the negative pressure needed for effective drainage.

Choice B Reason:

Clamp the chest tube prior to transferring the client to a wheelchair is incorrect. Clamping the chest tube can lead to a buildup of air or fluid in the pleural space, potentially causing a tension pneumothorax. The chest tube should remain unclamped to allow continuous drainage.

Choice C Reason:

Empty the collection chamber prior to transport is incorrect. While it is important to monitor and manage the drainage, emptying the collection chamber is not necessary before transport. The focus should be on maintaining the integrity and function of the drainage system.

Choice D Reason:

Disconnect the chest tube from the drainage system during transport is incorrect. Disconnecting the chest tube can lead to a loss of the negative pressure system, resulting in potential complications such as pneumothorax. The chest tube should remain connected to ensure continuous drainage and maintain the negative pressure.

Correct Answer is ["1"]

Explanation

We know:

The prescribed dose is 25 mg.
The available concentration is 125 mg per 5 mL.

Step 2 is to set up the calculation.

We will use the formula: (Desired Dose in mL) = (Prescribed Dose in mg × Volume Available in mL) ÷ Concentration Available in mg

Step 3 is to plug in the values into the formula.

(Desired Dose in mL) = (25 mg × 5 mL) ÷ 125 mg

Step 4 is to perform the multiplication first.

25 mg × 5 mL = 125

Step 5 is to perform the division.

125 ÷ 125 mg = 1 mL

Step 6 is the result.

The nurse should administer 1 mL per dose.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which measure is important for the nurse to take?

Correct Answer is A

Explanation

Correct Answer is ["1"]

Explanation

A nurse is preparing to administer digoxin 1.5 mg PO to a client. The amount available is digoxin 0.5 mg tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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