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) Sims': This position is not ideal for clients with increased intracranial pressure (ICP) because it does not promote optimal venous drainage from the brain.
B) Left lateral: While side-lying positions may be comfortable, they are not recommended for clients with increased ICP as they can hinder venous return from the head and neck.
C) Supine: Lying flat can increase ICP due to decreased venous drainage. It is generally not recommended for managing elevated ICP.
D) Low-Fowler's: This is the correct answer. Positioning the client in a Low-Fowler's position (typically with the head elevated 30 degrees) promotes venous drainage from the brain, which can help lower intracranial pressure and improve cerebral perfusion.
Correct Answer is B
Explanation
A) Advising the client to limit foods containing vitamin D is not appropriate. Phenytoin can lead to decreased vitamin D levels, making it important to maintain adequate vitamin D intake to support bone health. Therefore, there is no need to restrict these foods.
B) Taking phenytoin with food can help reduce gastrointestinal side effects and improve absorption, making this instruction crucial for the client’s adherence to the medication regimen. It is important for older adults, who may be more sensitive to medications, to have guidance on how to take their medications effectively.
C) Planning to take phenytoin with antacids is not advisable, as antacids can interfere with the absorption of phenytoin. The nurse should instruct the client to space these medications apart to avoid reduced effectiveness of phenytoin.
D) Limiting foods that contain folic acid is unnecessary and not typically advised. In fact, folic acid is important for overall health, and some patients on phenytoin may need additional folic acid supplementation, especially if they have a deficiency. Therefore, this instruction may lead to unintended nutritional deficiencies.
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