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 A
Explanation
A. Provide the client with large-handled eating utensils: This intervention is beneficial for clients with multiple sclerosis, as it can help improve their grip and ease the process of eating. This is particularly important for clients who may experience weakness or coordination issues.
B. Touch the client's arm before beginning to speak: While this may be a considerate gesture for individuals with hearing impairments, it is not specifically targeted to address barriers faced by clients with multiple sclerosis, who may have visual or cognitive challenges.
C. Establish alternatives to verbal conversation: While offering alternative communication methods can be helpful, the primary barriers for many clients with multiple sclerosis often relate to physical function rather than communication alone.
D. Use the numbers on a clock to describe the position of food on the client's plate: This technique can be useful for clients with visual impairments, but it does not directly address the motor and coordination challenges often faced by clients with multiple sclerosis in daily tasks like eating.
Correct Answer is A
Explanation
A) Have the child take a tub bath each morning:Warm tub baths can help alleviate morning stiffness and improve joint mobility in children with juvenile idiopathic arthritis. This intervention can be soothing and help the child start the day with less discomfort, promoting better overall function and quality of life.
B) Encourage the child to take naps during the day:While rest is important, excessive napping can lead to decreased physical activity, which may worsen joint stiffness and reduce muscle strength. It is more beneficial to encourage regular, gentle exercise and activity throughout the day.
C) Apply splints to the child’s extremities during the day:Splints are typically used at night to prevent joint deformities and maintain proper alignment. During the day, it is important for the child to remain active and use their joints to maintain mobility and strength.
D) Keep the child on bedrest as long as pain persists:Prolonged bedrest can lead to muscle atrophy and joint stiffness, which can worsen the child’s condition. Encouraging gentle movement and activity, even when experiencing pain, is crucial for managing juvenile idiopathic arthritis effectively.
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.