A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

The first 2 min

The final 2 min

The final 15 min

The first 15 min

Answer and Explanation

The Correct Answer is D

A. The first 2 min - This is too short a period to monitor effectively for transfusion reactions.

B. The final 2 min - Transfusion reactions are more likely to occur at the beginning of the transfusion rather than at the end.

C. The final 15 min - While it’s still important to monitor, reactions are most likely to be detected earlier in the infusion.

D. The first 15 min - Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for any signs of a reaction, such as fever, chills, rash, or difficulty breathing.

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Correct Answer is A

Explanation

A. Airway obstruction - Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and potential inhalation injury. Ensuring a patent airway is the priority as it is critical for oxygenation and survival.

B. Paralytic ileus - While possible, a paralytic ileus is not an immediate life-threatening condition compared to airway obstruction.

C. Infection - Infection is a significant concern in burn patients, but it is a secondary priority after securing the airway.

D. Fluid imbalance - Fluid management is crucial in burn care, but securing the airway takes precedence due to the immediate risk to life from airway obstruction.

A. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow" B. Vision changes occur when retinal tissue pulls away from the blood vessels in the eye " C. Vision changes occur when the retina gins to breakdown and collect bits of debris D. Vision changes occur when the cloudy lens alters the passage of light through the eye”

Correct Answer is B

Explanation

A. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow." This describes acute angle-closure glaucoma, not retinal detachment.

B. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye." Retinal detachment happens when the retina separates from its supporting tissues, including the blood vessels, leading to vision loss.

C. "Vision changes occur when the retina begins to break down and collect bits of debris." This describes age-related macular degeneration, not retinal detachment.

D. "Vision changes occur when the cloudy lens alters the passage of light through the eye." This describes cataracts, not retinal detachment.

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A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

Nursing Test Bank

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A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is A

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Correct Answer is B

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A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?