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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Correct Answer is D

Explanation

Choice A Reason:

Defamation of character is incorrect. Defamation of character involves making false statements about someone that damage their reputation. This can be in the form of slander (spoken) or libel (written). Applying restraints without proper justification does not fall under defamation of character.

Choice B Reason:

Invasion of privacy is incorrect. Invasion of privacy involves intruding into someone’s personal life without consent. This can include unauthorized access to personal information or spaces. Applying restraints without proper justification is not an invasion of privacy.

Choice C Reason:

Slander is incorrect. Slander is a form of defamation that involves making false spoken statements that damage someone’s reputation. Applying restraints without proper justification does not involve making false statements.

Choice D Reason:

False imprisonment is correct. False imprisonment involves restraining a person without legal justification or their consent. In a healthcare setting, applying restraints without proper justification or following legal and ethical guidelines constitutes false imprisonment and violates the client’s rights.

A. Promotes the flow of secretions to the base of the lungs. B. Eliminates the need to cough. C. Helps clear the airways of excessive secretions. D. Limits the production of bronchial mucus.

Correct Answer is C

Explanation

Choice A reason: While chest physiotherapy can help mobilize secretions, it does not specifically promote the flow of secretions to the base of the lungs. The primary goal is to loosen and mobilize secretions so they can be coughed up and cleared from the airways. This helps improve overall lung function and oxygenation.

Choice B reason: Chest physiotherapy does not eliminate the need to cough. In fact, coughing is an essential part of the process as it helps expel the loosened secretions from the airways. The therapy aims to make coughing more effective by loosening the mucus.

Choice C reason: The primary purpose of chest physiotherapy with percussion and vibration is to help clear the airways of excessive secretions. This is particularly important for patients with conditions like chronic obstructive pulmonary disease (COPD), cystic fibrosis, or pneumonia, where mucus buildup can obstruct the airways and impair breathing. By loosening and mobilizing the secretions, the therapy facilitates their removal through coughing.

Choice D reason: Chest physiotherapy does not limit the production of bronchial mucus. It focuses on clearing existing mucus from the airways rather than reducing its production. The production of mucus is influenced by underlying conditions and may require other treatments to manage.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A primary health care provider orders chest physiotherapy with percussion and vibration for a client. After the health care provider leaves, the client says, “I still don’t understand the purpose of this therapy.” Which statement should be included in the nurse’s response?

Correct Answer is C

Explanation

A nurse is preparing an educational program about client confidentiality. The nurse should explain that nurses may share a client’s protected health information with which individuals?

A client wants to start doing magnet therapy. The nurse should explain to the client, which would be a contraindication for the use of magnet therapy?

A nurse is teaching a client who is obese and has obstructive sleep apnea on how to decrease the number of nightly apneic episodes. Which client statement indicates an understanding of the teaching?

A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which action should the nurse plan to take?

A nurse is giving preoperative instructions to a patient scheduled for surgery. The patient tells the nurse, “I will prepare my advance directives before I come to the hospital.” Which statement shows the client understands advance directives?

A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?