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 C
Explanation
A) Flushing: Flushing can occur as the body tries to regulate temperature, but it is not typically an adverse reaction to cooling measures.
B) Restlessness: While restlessness can indicate discomfort, it is not a specific sign of an adverse reaction to cooling therapy.
C) Shivering: This is the correct answer. Shivering is a direct response to cold exposure and indicates that the body is trying to generate heat in response to the cooling blanket. It can be an adverse reaction as it can increase metabolic demand and may counteract the intended effects of the cooling.
D) Tachycardia: Although an increase in heart rate can occur with fever or anxiety, it is not a definitive indicator of an adverse reaction to cooling. It can also be a normal physiological response.
Correct Answer is D
Explanation
A. Face: While jaundice can sometimes be observed on the face, it is not the most reliable area for assessment in clients with dark skin, as changes may be less visible due to pigmentation.
B. Palms of the hands: The palms can show signs of jaundice, but they may not be the best area to assess for this condition in clients with darker skin tones. Jaundice is typically more detectable in areas with less pigmentation.
C. Shoulders: The shoulders do not provide a reliable assessment area for jaundice, as skin tone can vary widely and may obscure subtle changes in color.
D. Sclera: The sclera (the white part of the eye) is the most appropriate area to assess for jaundice, regardless of skin color. Yellowing of the sclera is a classic sign of jaundice and can be easily observed in clients with dark skin.
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