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?

Administer the blood via a 21-gauge IV needle.

Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion.

Check the client's vital signs from the previous shift prior to the initiation of the transfusion.

Set the IV infusion pump to administer the blood over 6 hr.

Answer and Explanation

The Correct Answer is B

A.   A larger-bore needle (usually 18- to 20-gauge) is recommended for blood transfusions to prevent hemolysis and ensure adequate flow rate.
B.   Flushing the tubing with 0.9% sodium chloride ensures that it is primed and free from air or any incompatible solutions before starting the blood transfusion.
C.   Vital signs should be checked immediately before, during, and after the transfusion to monitor for adverse reactions.
D.   Blood transfusions are typically completed over 2 to 4 hours, depending on the clinical context, to reduce the risk of complications.

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Correct Answer is B

Explanation

A. Obtain a blood specimen for ABG analysis. Important, but not the first action.

B. In a client with burn injuries experiencing signs of airway compromise (drooling, hoarseness), the first action should be to ensure adequate oxygenation. Applying 100% humidified oxygen can help manage potential airway edema.
C. Obtain a baseline ECG. Necessary for monitoring but secondary to securing the airway.
D. Insert an 18-gauge IV catheter. Essential for fluid resuscitation and medication administration, but after ensuring adequate oxygenation.

Correct Answer is []

Explanation

Based on the provided nurses' notes, the client exhibits symptoms that may suggest a brief psychotic disorder, characterized by delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. The client's history of similar episodes and family history could support this diagnosis. To assess the client's progress, the nurse should monitor the client's ability to care for themselves and assess any suicide risk due to the client's recent stressors and emotional state. Actions that could be beneficial include reducing external stimuli to prevent sensory overload and engaging with the client several times each day to establish trust, which can help alleviate anxiety and foster a therapeutic environment.

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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

A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

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