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) Acetaminophen: While acetaminophen can be effective for mild to moderate pain relief, it may not be the most appropriate choice for abdominal pain associated with cholelithiasis. Opioids or nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac are typically more effective for this type of pain.
B) Omeprazole: This medication is a proton pump inhibitor used primarily for reducing gastric acid secretion and is not indicated for pain management. It does not address the pain caused by cholelithiasis.
C) Metoclopramide: This medication is an antiemetic and prokinetic agent that may help with nausea and vomiting, but it does not directly alleviate pain. It would not be the first choice for pain management in this situation.
D) Ketorolac: This NSAID is effective for managing moderate to severe pain and is suitable for the type of pain associated with cholelithiasis. It has anti-inflammatory properties that can provide significant relief, making it the best option for the client's current symptoms.
Correct Answer is B
Explanation
A. Direct anyone who becomes angry to leave the room: This approach can escalate tensions and does not promote open communication. It might further alienate team members rather than helping to resolve the conflict.
B. Facilitate discussion until all parties agree: This is an effective mediation strategy. By facilitating open dialogue, the nurse manager allows all parties to express their viewpoints, which can lead to understanding and resolution of the conflict.
C. Establish demands from each party that allow for negotiations: While negotiating demands can be part of conflict resolution, focusing solely on demands might not address underlying issues or foster collaboration among team members.
D. Determine who is at fault in the situation: Focusing on blame can create a hostile environment and does not contribute to a constructive resolution. It is more effective to focus on the issues at hand and how to move forward rather than assigning fault.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.