A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke.
Which of the following information is the priority for the nurse to discuss?

Choosing an agency to provide home physical therapy.

Obtaining an alert system to get help in case of a fall.

Providing information about available transportation resources.

Reviewing information about support groups for individuals who have had a stroke.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Choosing an agency to provide home physical therapy is important, but it is not the priority in this situation. The client's safety and immediate needs should be addressed first.

Choice B rationale:

Obtaining an alert system to get help in case of a fall is the priority for an older adult living alone with left-sided weakness following a stroke. Falls can result in serious injuries, so having an alert system ensures the client can call for assistance promptly, enhancing their safety and well-being.

Choice C rationale:

Providing information about available transportation resources is important for the client's long-term independence and quality of life. However, immediate safety concerns, such as the risk of falls, should be addressed first.

Choice D rationale:

Reviewing information about support groups for individuals who have had a stroke is essential for the client's emotional well-being and social support. However, immediate safety measures, such as fall prevention, take precedence in this scenario.

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Correct Answer is ["A","D"]

No explanation

A. Store the unit of blood at room temperature for 1 hr prior to the infusion. B. Ensure that the transfusion is completed within 6 hr. C. Obtain venous access using a 22-gauge needle. D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.

Correct Answer is D

Explanation

The correct answer is D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.

Choice A reason: Storing a unit of blood at room temperature for 1 hour prior to the infusion is not recommended. Blood products should be kept refrigerated until just before the transfusion to minimize the risk of bacterial contamination. The recommended storage temperature for packed RBCs is 1-6°C. If blood is left at room temperature, it should be infused within 30 minutes to ensure safety.

Choice B reason: Ensuring that the transfusion is completed within 6 hours is not correct. The standard practice is to complete a blood transfusion over 2 to 4 hours, depending on the volume and the patient’s condition. This is to reduce the risk of bacterial growth and transfusion reactions. Prolonging the transfusion time beyond 4 hours increases the risk of bacterial contamination and can compromise the efficacy of the transfused red blood cells.

Choice C reason: Obtaining venous access using a 22-gauge needle is not ideal for a transfusion of packed RBCs. A larger bore needle, typically an 18-gauge or 20-gauge, is preferred to ensure adequate flow of the viscous packed RBCs and to prevent hemolysis. The smaller the gauge number, the larger the needle diameter, so a 22-gauge needle might be too small and could damage the red blood cells during the transfusion.

Choice D reason: Using a solution of 0.9% sodium chloride to flush the transfusion tubing is the correct action. Normal saline is isotonic and is the only fluid compatible with packed RBCs. It is used to prime the transfusion set and to flush the line before and after the transfusion to prevent hemolysis and clotting within the tubing.

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A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke.Which of the following information is the priority for the nurse to discuss?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in an acute care setting. Exhibits The client is at risk for ________ as evidences by __________. Complete the following sentence by using the list of options. Pick 2 choices.

Correct Answer is ["A","D"]

A nurse is planning care for a client who is scheduled to receive a transfusion of packed RBCs. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke.
Which of the following information is the priority for the nurse to discuss?