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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d) Tighten the abdominal muscles while exhaling.
Choice A Reason:
“Raise both shoulders while breathing deeply” is incorrect. Diaphragmatic breathing focuses on using the diaphragm rather than the shoulders. Raising the shoulders can lead to shallow chest breathing, which is less effective for oxygen exchange.
Choice B Reason:
“Inhale through the mouth” is incorrect. For diaphragmatic breathing, it is recommended to inhale through the nose. This helps filter, warm, and humidify the air before it reaches the lungs.
Choice C Reason:
“Exhale through the nose” is incorrect. While exhaling through the nose is beneficial in some breathing exercises, diaphragmatic breathing typically involves exhaling through pursed lips. This technique helps slow down the exhalation and keeps the airways open longer.
Choice D Reason:
“Tighten the abdominal muscles while exhaling” is correct. Tightening the abdominal muscles helps push the diaphragm up, forcing air out of the lungs more efficiently. This action is a key component of effective diaphragmatic breathing.
Correct Answer is C
Explanation
Choice A reason: Apple juice is an appropriate choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without putting strain on the digestive system. Apple juice is easily digestible and does not contain any solid particles that could be problematic for a client recovering from abdominal surgery.
Choice B reason: Smoothies can be included in a full liquid diet as long as they are well-blended and do not contain any solid chunks. Smoothies can provide essential nutrients and calories, which are important for recovery. They can be made with fruits, vegetables, and protein supplements to ensure a balanced intake.
Choice C reason: Mashed potatoes and gravy are not suitable for a full liquid diet. Although mashed potatoes are soft, they are not liquid and can be difficult to digest for someone on a full liquid diet. The gravy may also contain small particles or thickeners that are not appropriate for this diet. A full liquid diet is intended to include only foods that are completely liquid or will turn to liquid at room temperature.
Choice D reason: Chicken broth is an excellent choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without adding any solid particles to the diet. Chicken broth is gentle on the digestive system and can help maintain electrolyte balance.
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