A nurse is caring for a client with an order for one unit of packed red blood cells (PRBCs). The nurse should anticipate to remain ate client's bedside during which time period of the infusion?

The first 2 min

The final 15 min

The first 15 min

The final 2 min

Answer and Explanation

The Correct Answer is C

A) The first 2 min: While it is essential to monitor the client closely during the first few minutes of a PRBC infusion, a two-minute observation period is insufficient to detect most acute transfusion reactions. Many reactions, such as fever, chills, and allergic responses, can take longer to manifest.

B) The final 15 min: Monitoring during the final 15 minutes is important to ensure the infusion is completed without complications. However, the most critical time for monitoring is at the beginning of the infusion, as acute reactions are more likely to occur early on.

C) The first 15 min: The first 15 minutes of a PRBC transfusion are crucial because most acute transfusion reactions, such as allergic reactions, febrile non-hemolytic reactions, and hemolytic reactions, occur within this time frame. The nurse should remain at the bedside to promptly identify and manage any adverse reactions, ensuring the client's safety.

D) The final 2 min: Monitoring during the final two minutes of the infusion is also important, but it is not the critical time frame for detecting most transfusion reactions. Observing the client closely during the initial phase of the transfusion is essential to address any immediate complications.

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Correct Answer is C

Explanation

A) The client's daily calorie intake: While daily calorie intake is important for understanding a client's nutritional needs and managing their diet, it is not required for calculating BMI. BMI calculation focuses on weight and height rather than caloric intake.

B) The client's waist circumference: Waist circumference is useful for assessing abdominal fat distribution and risk of obesity-related conditions, but it is not needed for calculating BMI. BMI calculation requires height and weight, not waist measurements.

C) The client's height: To calculate BMI, the client's height is essential. BMI is determined by dividing weight in kilograms by the square of height in meters (kg/m²). Accurate height measurement is crucial for this calculation.

D) The client's skinfold thickness: Skinfold thickness measurements are used to estimate body fat percentage but are not required for calculating BMI. BMI relies solely on weight and height, not body fat estimates.

A. Edema B. Oliguria C. Hypotension D. Hyperthemia

Correct Answer is A

Explanation

A) Edema: Fluid volume overload often leads to edema due to the excess fluid leaking out of the blood vessels into the interstitial spaces. This swelling is commonly observed in areas such as the ankles, legs, and hands.

B) Oliguria: Oliguria, or reduced urine output, is more indicative of fluid volume deficit or kidney dysfunction rather than overload. In fluid volume overload, the kidneys typically produce more urine to try to balance the excess fluid.

C) Hypotension: Fluid volume overload usually causes an increase in blood pressure rather than hypotension. Hypotension is more commonly associated with fluid volume deficit or severe fluid loss.

D) Hyperthermia: Hyperthermia is not a direct result of fluid volume overload. It is more related to conditions involving fever or infection. Fluid overload primarily affects fluid distribution and does not directly cause an increase in body temperature

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A nurse is caring for a client with an order for one unit of packed red blood cells (PRBCs). The nurse should anticipate to remain ate client's bedside during which time period of the infusion?

Nursing Test Bank

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