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) Flumazenil: Flumazenil is a benzodiazepine antagonist used to reverse the effects of benzodiazepine overdose. Since the client received hydromorphone, which is an opioid, flumazenil would not be the appropriate medication to administer in this situation. The respiratory depression is likely due to opioid use, so this option does not address the client’s specific needs.
B) Protamine: Protamine is a medication used to reverse the effects of heparin, an anticoagulant. It is not indicated for opioid overdose or respiratory depression caused by opioids. Therefore, administering protamine would not be relevant in this scenario and would not help address the client's low respiratory rate.
C) Acetylcysteine: Acetylcysteine is primarily used as an antidote for acetaminophen overdose and to help loosen mucus in conditions like cystic fibrosis. It does not have a role in reversing opioid effects. The client’s respiratory depression following hydromorphone administration would not be treated with acetylcysteine.
D) Naloxone: Naloxone is an opioid antagonist specifically designed to reverse the effects of opioid medications, including respiratory depression. Given that the client is experiencing a significantly low respiratory rate of 10/min after receiving hydromorphone, naloxone is the most appropriate medication to administer promptly to restore normal respiratory function.
Correct Answer is C
Explanation
A. Metallic taste in mouth: This is not a commonly reported adverse effect of sertraline. While some medications may cause changes in taste, it is not characteristic of SSRIs like sertraline.
B. Increased urinary frequency: This is not a typical adverse effect associated with sertraline. While changes in urinary patterns can occur with some medications, it is not specifically noted for sertraline.
C. Excessive sweating: This is a recognized adverse effect of sertraline and other SSRIs. Patients may experience increased sweating, which can be uncomfortable and distressing.
D. Dry cough: This is not a common side effect of sertraline. While some medications may lead to respiratory side effects, it is not typical for SSRIs like sertraline to cause a dry cough.
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