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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Urinary retention. Morphine is an opioid analgesic that can cause urinary retention by inhibiting bladder contractions and increasing sphincter tone. Urinary retention can lead to urinary tract infections, bladder distension, and renal impairment if not treated.
Correct Answer is D
Explanation
Choice A rationale:
Maintaining eye contact with the newborn during feedings is a general caregiving practice and is not specific to managing neonatal abstinence syndrome. While eye contact and bonding are important for newborns, it does not address the symptoms of neonatal abstinence syndrome.
Choice B rationale:
Swaddling the newborn with his legs extended is not a specific action for managing neonatal abstinence syndrome. However, swaddling can provide comfort to some infants, but the positioning of the legs is not directly related to managing symptoms of withdrawal.
Choice C rationale:
Administering naloxone to the newborn is not a standard practice for managing neonatal abstinence syndrome. Naloxone is an opioid antagonist used to reverse opioid overdose in adults and is not typically used in newborns unless there are specific indications, which are rare.
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