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.

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Correct Answer is A

Explanation

A. Slow and steady bubbling in the suction control chamber is expected and indicates that the system is functioning properly. It is designed to regulate the pressure within the chest cavity by allowing excess air and fluid to escape, ensuring that the lungs can re-expand properly
B. Checking for leaks is are unnecessary as the system is functioning as expected.
C. Checking the suction control outlet is are unnecessary as the system is functioning as expected.
D. Clamping the chest tube is are unnecessary as the system is functioning as expected.

A. Metabolic alkalosis B. Metabolic Acidosis C. Respiratory alkalosis D. Respiratory acidosis

Correct Answer is D

Explanation

A. Metabolic acidosis is characterized by a primary decrease in bicarbonate (HCO₃⁻) levels, which is not typically a direct result of COPD. However, if a patient with COPD has an additional condition like kidney failure or severe sepsis, they could potentially develop metabolic acidosis. But, this is not the primary concern in COPD.
B. Respiratory alkalosis is caused by hyperventilation, where there is excessive loss of CO₂ leading to an increase in blood pH. This is less common in COPD patients, as they typically have difficulty exhaling CO₂ rather than hyperventilating.
C. Metabolic alkalosis involves an increase in blood pH due to elevated bicarbonate levels or loss of acid. This is not typically associated with COPD, unless there is an unrelated condition causing metabolic alkalosis.
D. COPD is characterized by impaired airflow and reduced ability to expel carbon dioxide (CO₂) effectively. As CO₂ accumulates in the blood, it combines with water to form carbonic acid, which lowers the blood pH, leading to respiratory acidosis.

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

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Naxlex Comprehensive Predictor Exams

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