A nurse is planning to administer a unit of PRBCS for a client. Which of the following actions should the nurse plan to take?

Stay with the client for the first 10 min after starting the transfusion.

Flush the transfusion tubing with 5% dextrose in water.

Ensure 2 nurses check the label on the unit of blood.

Administer the blood transfusion over 1 hr.

Answer and Explanation

The Correct Answer is C

A.   The correct actions to take include staying with the client for the first 15-30 minutes after starting the transfusion, not just the first 10 minutes, to monitor for any adverse reactions.
B.   It is also crucial to use 0.9% sodium chloride solution, not 5% dextrose in water, to flush the transfusion tubing.
C.   It is a standard practice to have two nurses check the blood unit label to verify the correct blood type and compatibility before administration.
D.   The transfusion should not be rushed over 1 hour; instead, it should be administered over a period of 2-4 hours, depending on the patient's condition and the volume of PRBCs to be transfused.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. While important for overall patient assessment, it's not the most direct way to monitor for a wound infection.
B. Pain can indicate a wound infection, but it's not as specific as directly inspecting the wound.
C. This is the most direct way to assess for early signs of a wound infection. Redness, swelling, warmth, and drainage are classic signs of infection.
D. Important for overall patient care, but not specifically related to wound infection prevention.

A. "I will perform deep breathing exercises only when the pain is minimal." B. "I will perform deep breathing exercises every hour while awake." C. “I will perform coughing exercises only if I feel short of breath." D. "I will avoid deep breathing exercises to prevent straining my incision."

Correct Answer is B

Explanation

A. Deep breathing exercises should be performed regularly, regardless of the level of pain. The exercises are crucial for preventing lung complications, and pain management should be addressed so that the client can perform these exercises effectively.
B. This statement reflects a proper understanding of the importance of regular deep breathing exercises. Performing these exercises every hour while awake helps to keep the alveoli open and reduces the risk of atelectasis and pneumonia. Consistent practice is essential for maximizing lung expansion and preventing complications.
C. Coughing exercises should be performed regularly, not just when experiencing shortness of breath. Coughing helps to clear secretions from the airways and prevent their accumulation, which can lead to respiratory infections and other complications.
D. Avoiding deep breathing exercises is not advisable. While there may be some discomfort, deep breathing is essential for lung health post-operatively. The exercises help prevent complications such as atelectasis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning to administer a unit of PRBCS for a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A post-operative patient is at risk for developing a wound infection. Which of the following nursing assessments is the highest priority to prevent this complication?

Correct Answer is C

Explanation

The nurse emphasizes the importance of deep breathing and coughing exercises post-operatively to prevent complications. Which statement by the client indicates understanding of these exercises?

Correct Answer is B

Explanation

Which of the following medications from a client's medication list would increase their surgical risk?

A nurse is teaching a newly licensed nurse about a nonrebreather oxygen mask. Which of the following instructions should the nurse include?

During the preoperative period, what is the nurse's responsibility regarding informed consent?

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select All that Apply.)

A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?