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?

Store the unit of blood at room temperature for 1 hr prior to the infusion.

Ensure that the transfusion is completed within 6 hr.

Obtain venous access using a 22-gauge needle.

Use a solution of 0.9% sodium chloride to flush the transfusion tubing.

Answer and Explanation

The Correct Answer is D

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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Correct Answer is A

Explanation

Choice A rationale:

Distributive justice refers to the fair distribution of resources, benefits, and burdens in society. Ensuring that a homeless client receives preventive medical care exemplifies distributive justice as it promotes equal access to healthcare resources for all individuals, regardless of their housing situation.

Choice B rationale:

Being honest with the parents of a child about the need to report suspected abuse is an example of veracity, which is the duty to tell the truth. While honesty is important, it does not directly relate to distributive justice.

Choice C rationale:

Accepting the decision of an older adult client to live alone in her home respects the client's autonomy and independence but does not specifically demonstrate distributive justice.

Choice D rationale:

Keeping a promise to visit with a housebound client is an example of fidelity, the duty to fulfill promises. While it is ethically important, it does not exemplify distributive justice, which pertains to fair resource allocation.

A. Give antihypertensive medication. B. Perform a vaginal examination every 12 hr. C. Provide a low-stimulation environment. D. Administer betamethasone. E. Obtain a 24-hr urine specimen. F. Monitor intake and output hourly. G. Maintain bed rest.

Correct Answer is ["A","C","D","E","F","G"]

Explanation

The correct answers are Choices A, C, D, E, F, and G.

Choice A rationale: Antihypertensive medication is indicated due to sustained elevated BP (≥160/110 mm Hg), which increases risk for stroke, placental abruption, and eclampsia. Prompt control reduces maternal and fetal morbidity.

Choice B rationale: Routine vaginal exams are contraindicated unless signs of labor are present. Frequent exams increase infection risk and are not part of standard care for hypertensive or preeclamptic clients.

Choice C rationale: A low-stimulation environment (dim lights, quiet room) reduces CNS irritability and seizure risk in preeclampsia. It supports neuroprotection and aligns with seizure precaution protocols.

Choice D rationale: Betamethasone promotes fetal lung maturity in preterm gestation when delivery is likely. It reduces neonatal respiratory distress syndrome and improves outcomes in hypertensive pregnancies.

Choice E rationale: A 24-hour urine specimen quantifies proteinuria, essential for diagnosing preeclampsia severity. Protein 3+ on dipstick warrants confirmation via timed collection for accurate staging.

Choice F rationale: Hourly intake and output monitoring detects fluid shifts, renal compromise, and early signs of pulmonary edema. It’s critical in hypertensive disorders to guide fluid management.

Choice G rationale: Bed rest minimizes physical stress, stabilizes BP, and reduces risk of placental disruption. Left lateral positioning enhances uteroplacental perfusion and supports fetal oxygenation.

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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?

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Naxlex Comprehensive Predictor Exams

A community health nurse is working with a group of clients.The nurse practices the ethical principle of distributive justice by performing which of the following tasks?

Correct Answer is A

Explanation

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Correct Answer is ["A","C","D","E","F","G"]

Explanation

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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?