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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is A

Explanation

A) Perform the procedure prior to meals: This is the correct action. Postural drainage should ideally be performed before meals to minimize the risk of vomiting and to ensure the child is comfortable during and after the procedure.

B) Perform the procedure twice each day: While frequency may vary based on the child's needs, it is often recommended to perform postural drainage more frequently than twice a day, depending on the severity of the condition and the child's specific respiratory needs.

C) Administer a bronchodilator after the procedure: Bronchodilators are typically administered before postural drainage to help open the airways and improve the effectiveness of the drainage. Giving them after the procedure is not standard practice.

D) Hold hand flat to perform percussions on the child: The correct technique for performing chest percussion is to cup the hand slightly, creating a pocket of air that helps to effectively dislodge mucus. A flat hand can be less effective and may not provide the necessary impact.

A. Take magnesium hydroxide for indigestion. B. Eat 1 g/kg of protein per day. C. Consume foods high in potassium. D. Drink at least 3 L of fluid daily.

Correct Answer is B

Explanation

A) Take magnesium hydroxide for indigestion: This is not advisable for a client with chronic kidney disease (CKD) because magnesium can accumulate and lead to toxicity in individuals with impaired kidney function. Therefore, the nurse should recommend avoiding magnesium-based antacids.

B) Eat 1 g/kg of protein per day: This statement is correct. Clients on hemodialysis often require a higher protein intake to compensate for protein losses during dialysis. However, protein intake should be carefully monitored and tailored to individual needs and dialysis status.

C) Consume foods high in potassium: This instruction is inappropriate for a client with CKD. Elevated potassium levels (hyperkalemia) can be dangerous for these clients, so they should limit high-potassium foods to prevent complications.

D) Drink at least 3 L of fluid daily: This recommendation is not suitable for clients on hemodialysis, as fluid intake is typically restricted to prevent fluid overload. Fluid needs should be assessed based on the individual's condition and urine output, but generally, they should not drink excessive amounts.

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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?

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