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 A

Explanation

Rationale:

A. Administer diuretics: The client's symptoms, moist lung sounds, bounding pulse, elevated blood pressure, and pitting edema indicate fluid volume overload. Administering prescribed diuretics is the priority intervention to rapidly reduce intravascular and interstitial fluid volume and relieve pulmonary congestion.

B. Limit the client's fluid intake: Fluid restriction helps manage ongoing fluid retention but does not address the immediate concern of volume overload. It is a supportive measure rather than the initial priority in acute decompensated heart failure.

C. Insert an indwelling urinary catheter: While catheterization may help monitor output, it does not treat the underlying fluid excess. Inserting a catheter without addressing the fluid accumulation first does not provide immediate symptom relief.

D. Place the client on a low-sodium diet: A low-sodium diet is important for long-term management of heart failure, but it does not provide the prompt fluid removal needed in this acute situation. Immediate diuresis is necessary to reduce cardiac workload and respiratory distress.

A. A client who moved to an apartment located on higher ground than her previous home. B. A client who has frequent nightmares about the hurricane. C. A client who expresses a realization that life will not return to the way it was before the hurricane. D. A client who describes having persistent feelings of anger about the hurricane. E. A client who describes feeling disconnected from those around him following the hurricane.

Correct Answer is ["B","D","E"]

Explanation

Rationale:

A. A client who moved to an apartment located on higher ground than her previous home: Relocating for safety is a rational coping mechanism and does not, on its own, indicate PTSD. This action reflects adaptation rather than signs of trauma-related distress.

B. A client who has frequent nightmares about the hurricane: Recurrent nightmares related to the traumatic event are a hallmark symptom of PTSD and suggest that the client is experiencing persistent re-experiencing of the trauma.

C. A client who expresses a realization that life will not return to the way it was before the hurricane: This statement reflects acceptance and realistic processing of the event, not necessarily indicative of emotional distress or dysfunction associated with PTSD.

D. A client who describes having persistent feelings of anger about the hurricane: Chronic irritability or anger following trauma is a recognized symptom of PTSD and may indicate the client is struggling with emotional regulation due to unresolved trauma.

E. A client who describes feeling disconnected from those around him following the hurricane: Emotional numbing or detachment from others is a common symptom of PTSD, often associated with difficulty in re-establishing interpersonal connections after trauma.

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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

A nurse is assessing a client who has heart failure. The client has moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following is the nurse's priority intervention?

Correct Answer is A

Explanation

A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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