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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. D-dimer blood test - A D-dimer test measures clot breakdown products in the blood. Elevated levels suggest the presence of an abnormal blood clot, such as in PE, although it is not specific.
B. Complete blood count (CBC) - A CBC is not typically used to diagnose PE. It may be ordered to check for other conditions or as part of the overall health assessment, but it doesn't confirm PE.
C. CT scan - A CT pulmonary angiography is the gold standard for diagnosing PE. It provides detailed images of the blood vessels in the lungs.
D. Chest x-ray - A chest x-ray is not diagnostic for PE. It is often performed to rule out other causes of the client’s symptoms (e.g., pneumonia, pneumothorax) but does not confirm the presence of a pulmonary embolism.
E. Lung ventilation and perfusion scan (VQ scan)
A VQ scan is another diagnostic tool for PE, especially in clients who cannot tolerate contrast dye required for CT scans. It assesses the ventilation and perfusion of the lungs and identifies mismatches suggestive of PE.
Correct Answer is D
Explanation
A. Sleep on the abdomen to facilitate wound healing: Clients are usually advised to avoid sleeping on the side of the operated eye or on the abdomen to prevent pressure on the eye.
B. Bend at the waist to pick objects up from the floor: Bending at the waist can increase intraocular pressure, which is not advisable post-surgery.
C. Notify the surgeon if white drainage develops on the eyelids: White drainage may be a sign of normal healing or minor irritation; however, yellow or green discharge would be more concerning for infection.
D. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Lifting heavy objects can increase intraocular pressure and potentially disrupt the healing process after cataract surgery. The client should avoid such activities to promote proper healing.
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