A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

1 hour

2 hours

3 hours

4 hours

Answer and Explanation

The Correct Answer is D

Choice A reason: Infusing packed RBCs over 1 hour is typically too rapid for most patients and can increase the risk of adverse reactions, especially in those with cardiovascular compromise.

Choice B reason: A 2hour infusion may be appropriate in certain emergency situations where rapid correction of anemia is required, but it is not the standard practice for routine transfusions.

Choice C reason: A 3hour infusion is less commonly used and does not provide any specific advantage over the standard 4hour infusion time.

Choice D reason: The standard practice is to complete the transfusion of packed RBCs within 4 hours. This duration minimizes the risk of bacterial growth and transfusion reactions, as recommended by the American Society of Hematology and other clinical guidelines.

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Correct Answer is C

Explanation

Choice A reason: Dehydration is a concern with fever, but it is not a direct complication of hypothermia blanket therapy. It is important to ensure adequate hydration, but the primary concern with hypothermia therapy is not dehydration.

Choice B reason: Burns could occur if the hypothermia blanket malfunctions or is used improperly. However, modern devices have safety features to prevent burns, making this a less likely complication.

Choice C reason: Shivering is a natural response to cooling and can occur as the body attempts to generate heat in response to the lowered temperature from the hypothermia blanket. It can be counterproductive to the therapy and may need to be controlled with medications.

Choice D reason: Seizures are not a typical complication of hypothermia blanket therapy. While meningitis can cause seizures due to inflammation of the brain, the hypothermia blanket itself does not induce seizures.

A. Perform neurological checks every 2 hours. B. Position the patient in a chair every 2 hours. C. Inspect clear drainage on the spinal dressing. D. Continue criminal checks.

Correct Answer is A

Explanation

Choice A reason: Neurological checks are essential after spinal surgery to monitor for any changes or deterioration in the patient's neurological status. The frequency of these checks can vary based on the patient's condition, but a common standard is to perform them every 4 hours or sooner. However, in some cases, especially immediately post operation, checks may be required more frequently, such as every 2 hours, to ensure any complications are identified and managed promptly.

Choice B reason: While mobilization is an important aspect of postsurgical care to prevent complications such as deep vein thrombosis, positioning a patient in a chair every 2 hours may not be appropriate immediately following spinal surgery. The patient's mobility and pain level must be assessed, and activities should be gradually increased as tolerated.

Choice C reason: Inspecting the spinal dressing is important to identify signs of infection or complications. However, clear drainage is not typically expected and could indicate cerebrospinal fluid leakage, which requires immediate medical attention.

Choice D reason: The term "criminal checks" is not relevant to nursing care and seems to be a typographical error. The nurse's focus should be on clinical assessments and interventions related to the patient's health status.

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A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has meningitis and a temperature of 39.7°C (103.5°F). The client is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must be carefully observed for which of the following complications?

Correct Answer is C

Explanation

A nurse is planning care for a client who has just had spinal surgery. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

A nurse is assessing a patient's immune function by reviewing the laboratory value of the cellular response of the T cells. The nurse should recognize that which of the following conditions is affected by the?

A nurse is assessing a client 15 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?

A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.8 g/dL. Which of the following foods should the nurse recommend?

A nurse is evaluating the laboratory report for a client who has severe diarrhea and a fever. Which of the following laboratory findings should the nurse identify as an indication that the client has a parasitic infection rather than a bacterial infection?

A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?