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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Have the child take a tub bath each morning: Warm tub baths are recommended for children with juvenile idiopathic arthritis (JIA) as they help to relieve joint stiffness and pain, especially in the morning. The warm water can soothe the joints, making movement easier and reducing discomfort throughout the day.
B. Apply splints to the child's extremities during the day: While splints may be used in JIA, they are typically applied during the night (resting splints) to maintain joint position and prevent contractures. Daytime use of splints (working splints) may be considered in certain situations, but generally, children are encouraged to be as active as possible during the day to maintain joint mobility.
C. Keep the child on bedrest as long as pain persists: Prolonged bedrest is not recommended for children with JIA. It can lead to muscle atrophy, increased stiffness, and reduced joint mobility. Instead, the focus should be on maintaining activity within the child's pain tolerance and using pain management strategies.
D. Encourage the child to take naps during the day: While rest is important, encouraging too much rest during the day may contribute to joint stiffness. Regular activity helps maintain joint function and mobility, which is essential in managing JIA.
Correct Answer is B
Explanation
A: Tachycardia might occur due to the fever itself but isn't a specific reaction to the cooling method.
B: Shivering is an adverse reaction because it indicates that the body is trying to generate heat to counteract the cooling effect of the blanket, which can increase metabolic demand and is counterproductive.
C: Flushing is typically related to fever or other causes but not directly to the adverse reaction of cooling.
D: Restlessness can be caused by discomfort or the fever itself, not specifically by cooling.
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