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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Correct Answer is C

Explanation

A. "That can't be true. The only voices in this room are yours and mine.": This response dismisses the client’s experience and can invalidate their feelings, which is not therapeutic or supportive.

B. "Do you recognize the voices as belonging to anyone you know?": While this question could gather more information, it might divert the focus from the client’s immediate feelings of fear and distress.

C. "I understand the voices are frightening you, but I do not hear any voices.": This response validates the client's experience of fear and acknowledges their distress while also gently indicating that the nurse does not perceive the voices. It encourages open communication about the client’s feelings.

D. "You shouldn't be afraid when you think the voices are telling you to hurt yourself.": This response is inappropriate as it minimizes the client’s feelings and does not address the seriousness of their statements about self-harm. It’s crucial to acknowledge their fear rather than dismissing it.

A. Exaggerated curvature of the sacrum B. Uneven shoulder and pelvic heights C. Mild pain in the hip region D. Limited range-of-motion of the hips

Correct Answer is B

Explanation

A) Exaggerated curvature of the sacrum: This is not a specific indicator of scoliosis. Scoliosis primarily involves lateral curvature of the spine, not an exaggerated curvature of the sacrum.

B) Uneven shoulder and pelvic heights: This is the correct answer. Scoliosis is characterized by an abnormal lateral curvature of the spine, which can lead to uneven shoulder and pelvic heights. This is a common clinical manifestation that nurses look for during screenings.

C) Mild pain in the hip region: While pain can sometimes accompany scoliosis, it is not a definitive clinical manifestation of the condition itself and is not typically used as an indicator during screenings.

D) Limited range-of-motion of the hips: Limited hip motion may occur due to other conditions but is not a primary sign of scoliosis. The assessment of scoliosis focuses more on spinal alignment and symmetry rather than hip mobility.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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