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

A) "My child has some swelling around her eyelids and mouth."

In this scenario, the parent reporting swelling around the toddler's eyelids and mouth after receiving immunizations is the nurse's priority concern. Swelling around the eyes and mouth can be indicative of a possible allergic reaction, such as angioedema or anaphylaxis, which can be a serious and life-threatening condition. Immediate assessment and intervention are needed to address this potential allergic reaction.

The other findings, while important, are not as immediately concerning:

B) A temperature of 100.7 degrees Fahrenheit is a mild fever, which can be expected as a side effect of some vaccines. It may not be the nurse's immediate priority, but it should still be monitored.

C) A toddler's decreased feeding of 2 ounces during her last feeding may be related to her discomfort or fever after immunizations. It's essential to monitor this but not an immediate priority.

D) Crying when touched at the injection site is a common response to immunizations and, while uncomfortable for the child, is not typically a cause for immediate concern. However, it should still be addressed with comfort measures.

A. Ensuring that a client who is homeless receives preventive medical care. B. Being honest with the parents of a child about the need to report suspected abuse. C. Accepting the decision of an older adult client to live alone in her home. D. Keeping a promise to visit with a client who is housebound after the delivery of care.

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.

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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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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?