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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. "Remove the patch for 8 hours every day to reduce the risk of tolerance.": This is incorrect. The fentanyl patch should be left in place continuously for the prescribed duration to maintain consistent pain relief and should not be removed unless instructed by a healthcare provider.

B. "Avoid hot tubs while wearing the patch.": This is an important instruction. Heat can increase the absorption of fentanyl from the patch, potentially leading to overdose. Therefore, avoiding hot tubs and other heat sources is crucial while using the patch.

C. "Avoid high-fiber foods while taking this medication.": This statement is not accurate. In fact, opioid medications like fentanyl often cause constipation, so high-fiber foods can be beneficial to help prevent this side effect.

D. "Apply the patch to your forearm.": This is not typically the recommended application site for fentanyl patches. They are usually applied to hairless areas of the upper body or upper outer arm, where they can adhere properly and be effective.

A. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. B. Initiate NPO status 4 hr prior to the procedure. C. Position the client over an overbed table prior to the procedure. D. Instruct the client to empty her bladder prior to the procedure.

Correct Answer is D

Explanation

A) Administer 1 L dextrose 5% in water IV bolus prior to the procedure: Administering a large volume IV bolus is generally unnecessary before a paracentesis. It can lead to abdominal distension and discomfort, potentially complicating the procedure. Fluid management should be carefully considered based on the client’s condition rather than a standard bolus.

B) Initiate NPO status 4 hr prior to the procedure: Paracentesis typically does not require NPO status unless sedation is planned, which is uncommon. Keeping the client NPO can cause unnecessary discomfort and does not align with standard pre-procedural care for a paracentesis, which usually allows for regular oral intake.

C) Position the client over an overbed table prior to the procedure: While positioning is crucial for comfort and access, clients are generally positioned sitting at the edge of the bed or in a semi-Fowler's position. An overbed table may not provide adequate support and could lead to discomfort or complications during the procedure.

D) Instruct the client to empty her bladder prior to the procedure: This action is important as it helps reduce the risk of bladder injury during the paracentesis and minimizes discomfort. An empty bladder allows for better access to the abdominal cavity, indicating that the nurse understands the necessary preparations for the procedure.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg/hr transdermal patch. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

A nurse is caring for a 30-month-old child. Which of the following activities should the nurse expect the child to participate in?

A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching?

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo an electroencephalogram (EEG) about the procedure. Which of the following instructions should the nurse include in teaching?

A nurse is caring for a client who has systemic lupus erythematosus. Which of the following client findings should the nurse expect?

A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse?