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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Correct Answer is D

Explanation

Rationale:

A. Use passive listening techniques during conflict resolution: Passive listening involves minimal engagement and can lead to misunderstandings or missed key concerns. Active listening is more effective in conflict resolution as it validates feelings and clarifies perspectives.

B. Ask closed-ended questions about the conflict: Closed-ended questions limit the depth of responses and may not fully uncover the underlying issues. Open-ended questions encourage dialogue and help reveal the root causes of conflict more effectively.

C. Ensure each individual can respond defensively about the conflict: Allowing or encouraging defensive responses can escalate tension and hinder resolution. A nonjudgmental and respectful environment promotes open communication and constructive problem-solving.

D. Gather individual information regarding the conflict: Collecting information from each party separately allows the nurse manager to understand different perspectives, identify miscommunications, and develop a balanced and informed approach to resolving the conflict.

A. Obtain a 12-lead ECG for the client. B. Have the client stop walking and sit down. C. Administer sublingual nitroglycerin to the client. D. Measure the client's vital signs.

Correct Answer is B

Explanation

Rationale:

A. Obtain a 12-lead ECG for the client: An ECG is important for diagnosing myocardial ischemia or infarction, but it is not the immediate first step. The priority is to stop activity and reduce myocardial oxygen demand before further diagnostics.

B. Have the client stop walking and sit down: Angina is often triggered by physical exertion. Stopping activity and sitting down reduces oxygen demand on the heart, alleviates symptoms, and prevents further ischemia. This is the most immediate and essential first action.

C. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve anginal pain by dilating coronary arteries, but it should be given after the client has stopped activity and rested. Administering it while the client is still active may not be effective or safe.

D. Measure the client's vital signs: While vital signs are important for assessing the client’s current status, the priority is to stop exertion, which is likely contributing to myocardial oxygen imbalance. Assessment follows immediate symptom relief measures.

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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

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