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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is D
Explanation
A) Isotonic solution: Isotonic solutions, such as 0.9% sodium chloride, maintain the current sodium levels and fluid balance but do not correct hypernatremia. They are not suitable for lowering elevated sodium levels.
B) Total Parenteral Nutrition (TPN): TPN is used for providing comprehensive nutritional support and does not address electrolyte imbalances such as hypernatremia. It is not used to manage sodium levels directly.
C) Hypertonic solution: Hypertonic solutions, such as 3% sodium chloride, increase sodium levels and are used for treating hyponatremia or specific conditions requiring higher sodium concentrations. They would worsen hypernatremia.
D) Hypotonic solution: Hypotonic solutions, like 0.45% sodium chloride (half-normal saline) or Dextrose 5% in water (D5W), are appropriate for treating hypernatremia. They help dilute the sodium concentration in the blood and aid in correcting the elevated sodium levels
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