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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Expect to have a rapid pulse rate for the first few weeks. B. Return in two weeks for a follow-up MRI. C. Resume tub baths and swimming after 24 hr. D. Wear loose-fitting clothing.

Correct Answer is D

Explanation

Choice A rationale:

Expecting to have a rapid pulse rate for the first few weeks is not accurate information for a client with a newly implanted implantable cardioverter-defibrillator (ICD). After the ICD placement, the client's heart rate should stabilize within normal ranges. A consistently rapid pulse rate might indicate an issue with the device or the client's cardiovascular system, necessitating further evaluation.

Choice B rationale:

Returning in two weeks for a follow-up MRI is not advisable immediately after ICD placement. MRI (Magnetic Resonance Imaging) is contraindicated for individuals with ICDs due to the magnetic fields, which can interfere with the functioning of the device. The timing and necessity of any future MRI should be carefully planned and discussed with the healthcare provider in charge of the client's care.

Choice C rationale:

Resuming tub baths and swimming after 24 hours is not recommended after ICD placement. Submerging the ICD site in water, especially in the initial healing phase, can increase the risk of infection. Clients with newly implanted ICDs are usually advised to avoid submerging the device site in water for a specified period, as recommended by their healthcare provider.

Choice D rationale:

Wearing loose-fitting clothing is important advice for clients with newly implanted ICDs. Tight clothing, especially around the site of the device, can cause irritation and discomfort. Loose-fitting clothing ensures proper airflow to the site, reducing the risk of irritation and allowing for optimal healing. It is essential to provide this information to the client to promote comfort and prevent complications related to the ICD placement.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin.Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

Correct Answer is D

Explanation

A nurse is planning teaching for a client who has a newly implanted implantable cardioverter-defibrillator.Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is assessing a client who has type 1 diabetes mellitus and was administered insulin lispro 1 hr ago.Which of the following manifestations indicates that the client might be experiencing hypoglycemia?

A nurse in an outpatient mental health clinic is assessing an adolescent client.The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?

A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?

A nurse is caring for a client who has heart failure.Which of the following manifestations should the nurse expect?

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago.The nurse notes pink-tinged urine in the drainage bag.Which of the following actions should the nurse take?

A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?

A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?

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?