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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Do you need information on hospice care?" While hospice care is important for terminally ill patients, this question may not directly address the client's feelings of depression or their immediate emotional needs.
B. "Do you need a prescription for an antianxiety medication?" This statement may not be appropriate at this time, as it suggests a focus on medication rather than exploring the client's feelings. It’s important to first assess the client’s emotional needs and discuss therapy options.
C. "Would you like to talk to a counsellor about advance directives?" This question shifts the focus from the client's feelings of depression to advance care planning, which may not be the most relevant topic at this moment.
D. "Would you like to speak to a spiritual advisor?" This statement acknowledges the client's emotional state and offers a supportive option for exploring feelings of depression, which can be beneficial for those facing terminal illness. Spiritual support can provide comfort and help the client process their emotions during this difficult time.
Correct Answer is C
Explanation
A) Taking your temperature 1 hour after getting out of bed is not appropriate for the basal body temperature method. For accurate tracking, temperature should be taken immediately upon waking, before any activity or movement that could affect the reading.
B) Taking your temperature every night before going to bed does not align with the basal body temperature method. This method requires consistent morning measurements to track ovulation accurately, as body temperature can fluctuate throughout the day.
C) Taking your temperature immediately after waking and before getting out of bed is the correct instruction. This ensures the reading reflects the body's resting temperature, which can help identify the slight increase that occurs after ovulation, aiding in family planning efforts.
D) Taking your temperature within 30 minutes after your first morning void is not suitable for this method. The ideal time is right upon waking, and any activity, including using the bathroom, can alter body temperature and lead to inaccurate readings.
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