A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

Assess the client's lung sounds prior to the infusion.

Infuse the blood over 4 hr.

Verify with another nurse that the unit of blood is compatible with the client's blood type

Prime the infusion tubing with 0.45% sodium chloride

Don sterile gloves to prepare the blood administration setup.

Answer and Explanation

Correct Answer : A,B,C

Rationale:

A. Assess the client's lung sounds prior to the infusion: Pre-transfusion assessment of lung sounds is essential to detect any baseline abnormalities and to monitor for fluid overload or transfusion-related lung complications such as transfusion-associated circulatory overload.

B. Infuse the blood over 4 hr: Older adults are at increased risk for fluid overload, so transfusing packed RBCs slowly over 4 hours is appropriate and safer, as long as the blood is completely administered within the maximum 4-hour window from removal from refrigeration.

C. Verify with another nurse that the unit of blood is compatible with the client's blood type: A dual verification process is mandatory to ensure safe administration. The nurse must check the client’s ID, blood type, unit number, and expiration date with another licensed professional before initiating the transfusion.

D. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime and flush blood transfusion tubing. Hypotonic solutions like 0.45% sodium chloride can cause hemolysis and should never be used with blood products.

E. Don sterile gloves to prepare the blood administration setup: Sterile gloves are not necessary for setting up a blood transfusion. Clean gloves are sufficient for handling equipment and initiating IV therapy, following standard precautions.

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

Rationale:

A. Keep objects in the client's room in the same place: Maintaining a consistent environment helps clients with vision loss navigate safely and confidently. Sudden changes in object placement can increase the risk of disorientation and injury.

B. Ensure there is high-wattage lighting in the client's room: While good lighting benefits clients with partial vision, high-wattage lighting can cause glare or discomfort. The focus should be on well-distributed, non-glare lighting suited to individual needs rather than universally high intensity.

C. Touch the client gently to announce presence: Gently touching a visually impaired client before speaking helps avoid startling them and fosters trust. It is a respectful way to make presence known when visual cues are unavailable.

D. Approach the client from the side: Approaching from the front is preferable so the client can better perceive the nurse's presence through remaining visual fields or auditory cues. Side approaches may lead to disorientation or surprise.

E. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to complete self-care or communication tasks. Rushing them can increase stress and compromise safety, so patience supports their independence.

A. Encourage the client and partner to avoid expressing negative feelings about the colostomy. B. Suggest the client join a support group for people who have colostomies. C. Instruct the client's partner to assume care of the colostomy for the client. D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy.

Correct Answer is B

Explanation

Rationale:

A. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing negative emotions can hinder psychological adjustment. Clients should be encouraged to express their feelings openly as part of the adaptation and coping process.

B. Suggest the client join a support group for people who have colostomies: Support groups can provide emotional reassurance, shared experiences, and practical coping strategies. Seeing others manage their stomas successfully can promote acceptance and self-confidence.

C. Instruct the client's partner to assume care of the colostomy for the client: While partner support is important, encouraging dependence may delay the client’s adjustment and self-care ability. The goal should be to promote independence and acceptance at the client’s pace.

D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: A transfer is not necessary unless the client has complex needs. Initial support, education, and emotional guidance should be provided in the current care setting.

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A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is B

Explanation

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