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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Discouraging the client from allowing friends to see the newborn may deprive the client of potential sources of support and comfort during the grieving process.
B. Avoiding talking to the client about the newborn may inhibit the client's ability to process their emotions and may convey a lack of support from the nurse.
C. While it is important to provide reassurance, assuring the client that she can have additional children may minimize the client's current grief and invalidate her feelings of loss.
D. Offering to take pictures of the newborn allows the client to create lasting memories and keepsakes, which can be comforting and therapeutic during the grieving process.
Correct Answer is B
Explanation
A. Limiting intake of dairy products may not directly address stomatitis unless the client has an intolerance or allergy to dairy.
B. Using a soft-bristle toothbrush helps prevent trauma to the oral mucosa, which can exacerbate stomatitis. Gentle oral care with a soft toothbrush after meals helps maintain oral hygiene without causing further irritation.
C. Moistening lips with lemon-glycerin swabs may further irritate the oral mucosa due to the acidic nature of lemon.
D. Gargling with an alcohol-based mouthwash can exacerbate stomatitis and should be avoided due to its drying effect on oral tissues.
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.