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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Related Questions
Correct Answer is D
Explanation
A. While completing an incident report is important for addressing the medication error and implementing corrective actions, the immediate priority is to assess the client's condition for signs of bleeding, which could be life-threatening.
B. Monitoring aPTT levels is important to assess the client's response to heparin therapy, but it does not address the immediate risk of bleeding from the overdose.
C. Notifying the risk manager is essential for reporting the medication error and implementing strategies to prevent future occurrences, but the nurse's first action should be to assess the client's condition for any indications of bleeding.
D. Administering a high dose of heparin increases the risk of bleeding, so the nurse should first assess the client for any signs or symptoms of bleeding, such as unexplained bruising, hematuria, or hypotension, to ensure timely intervention and prevent complication.
Correct Answer is A
Explanation
To calculate the IV infusion rate for dopamine hydrochloride, we first need to convert the dose from micrograms per kilogram per minute (mcg/kg/min) to milligrams per hour (mg/hr). The patient weighs 80 kg and the prescribed dose is 4 mcg/kg/min.
First, calculate the dose in mcg/hr: 4 mcg/kg/min x 80 kg x 60 min/hr = 19200 mcg/hr.
Next, convert mcg to mg: 19200 mcg/hr / 1000 mcg/mg = 19.2 mg/hr.
We have an 800 mg dopamine hydrochloride solution in a 250 mL bag. To find out how many mL/hr to administer, we use the following proportion:
(800 mg / 250 mL) = (19.2 mg / X mL).
Solving for X gives us X = (19.2 mg * 250 mL) / 800 mg, which equals 6 mL/hr.
Therefore, the nurse should set the IV infusion pump to deliver 6 mL/hr.
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