A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
Check the client's vital signs from the previous shift prior to the initiation of the transfusion.
Administer the blood via a 21-gauge IV needle.
Set the IV infusion pump to administer the blood over 6 hr.
Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion.
The Correct Answer is D
A) Check the client’s vital signs from the previous shift prior to the initiation of the transfusion: Checking the client’s vital signs from the previous shift is not sufficient. The nurse should obtain a set of baseline vital signs immediately before starting the transfusion to monitor for any changes or reactions during the procedure.
B) Administer the blood via a 21-gauge IV needle: A 21-gauge IV needle is too small for administering packed RBCs. A larger gauge needle, such as an 18- or 20-gauge, is recommended to ensure the blood flows smoothly and to reduce the risk of hemolysis.
C) Set the IV infusion pump to administer the blood over 6 hr: Administering the blood over 6 hours is not appropriate. Packed RBCs should be transfused within 4 hours to reduce the risk of bacterial contamination and ensure the blood remains viable.
D) Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion: Flushing the blood administration tubing with 0.9% sodium chloride is the correct action. This helps to clear the line of any residual substances and ensures that the blood product is delivered effectively and safely to the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Administer 0.9% sodium chloride IV: While fluid replacement is important in managing a thyroid storm, it is not the immediate priority compared to monitoring critical symptoms.
B) Provide a cooling blanket: Hyperthermia is a concern in a thyroid storm, and cooling measures are necessary, but they are secondary to addressing the cardiovascular effects.
C) Obtain the client's blood glucose: Monitoring blood glucose is important, especially in a hypermetabolic state, but it is not the most immediate concern in the context of a thyroid storm.
D) Monitor the client's cardiac rhythm: This is the priority action. Thyroid storm can cause significant cardiovascular complications, including tachycardia and arrhythmias. Continuous monitoring of the cardiac rhythm is essential to detect any life-threatening changes and to provide prompt intervention if necessary.
Correct Answer is C
Explanation
A. Obtain a trough level 30 min after the medication infusion: Trough levels should be drawn just before the next dose, not 30 minutes after the infusion. This timing ensures accurate measurement of the drug’s lowest concentration in the bloodstream.
B. Inject 1% lidocaine prior to each dose: While lidocaine may help reduce discomfort at the injection site, it is not a standard practice for all patients receiving vancomycin and does not address the risk of systemic adverse reactions.
C. Give the dose over 60 min: Administering vancomycin over a period of at least 60 minutes is essential to minimize the risk of infusion-related reactions, such as "red man syndrome," which can occur if the drug is infused too quickly.
D. Administer the medication undiluted: Vancomycin should always be diluted according to guidelines before administration to reduce the risk of irritation to the veins and potential adverse reactions. Administering undiluted increases the risk of complications.
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