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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:

“N95 (personal respirator mask)” is correct because varicella (chickenpox) is an airborne disease. The N95 mask is designed to filter out at least 95% of airborne particles, making it essential for protecting healthcare workers from inhaling infectious agents.

Choice B Reason:

“Surgical mask” is incorrect because while surgical masks provide a barrier against large respiratory droplets, they do not offer sufficient protection against airborne particles. Varicella can be transmitted through tiny airborne droplets, which necessitates the use of an N95 mask.

Choice C Reason:

“They don’t need a mask” is incorrect because healthcare workers must wear appropriate personal protective equipment (PPE) to prevent the spread of infectious diseases. Not wearing a mask would put the nurse at risk of contracting varicella.

Choice D Reason:

“Only the client needs a mask” is incorrect because while it is important for the client to wear a mask to reduce the spread of infectious droplets, the nurse also needs to wear an N95 mask to protect themselves from airborne transmission.

A. Gastrocnemius B. Dorsogluteal C. Vastus lateralis D. Ventrogluteal

Correct Answer is C

Explanation

Choice A Reason:

The gastrocnemius muscle, located in the calf, is not a recommended site for intramuscular injections in newborns. This muscle is not typically used due to its small size and the difficulty in accessing it safely for an injection.

Choice B Reason:

The dorsogluteal muscle, located in the buttocks, is also not recommended for newborns. This site is avoided because of the risk of damaging the sciatic nerve and the relatively thick layer of subcutaneous fat, which can interfere with the absorption of the medication.

Choice C Reason:

The vastus lateralis muscle, located in the thigh, is the preferred site for intramuscular injections in newborns. This muscle is well-developed at birth and provides a large, easily accessible area for injections. It is also away from major blood vessels and nerves, making it a safe and effective site for administering medications like vitamin K.

Choice D Reason:

The ventrogluteal muscle, located on the side of the hip, is another site used for intramuscular injections, but it is not typically recommended for newborns. This site is more commonly used in older children and adults due to its deeper location and the need for precise anatomical knowledge to avoid complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client admitted with a rash. They are trying to rule out (r/o) varicella. Before entering the room, the nurse should be instructed to wear what kind of mask?

Correct Answer is A

Explanation

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which muscle?

Correct Answer is C

Explanation

A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

A nurse is caring for a client who will be placed on strict bed rest after surgery. The nurse should educate the client on the use of an incentive spirometer. The use of an incentive spirometer would prevent which postoperative complication?

A nurse is monitoring the urinary output of a client who had a colon resection. Which 24-hour output total indicates oliguria?

A nurse is caring for a client with a chest tube. Which action should the nurse take?

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?

A client has an injury to the left ankle requiring partial weight bearing. The client is elderly with a history of balance deficit. Which assistive device would be most appropriate for this client?

A nurse is demonstrating to a client how to perform diaphragmatic breathing. The nurse should educate the client to complete which action?

Edited TextA nurse is auditing a client. During the assessment, the nurse notes the client has multiple cavities, chipped, and missing teeth. The client reports having difficulty eating. Which diet should the nurse recommend the primary health care provider to order for this client?