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.
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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Related Questions
Correct Answer is D
Explanation
A. Murmurs are usually related to valve dysfunctions, such as tricuspid or pulmonic valve issues, which may or may not be present in right-sided heart failure.
B. Crackles (or rales) are more commonly associated with left-sided heart failure. They result from fluid accumulation in the lungs (pulmonary congestion) due to the heart's inability to handle the blood returning from the lungs.
C. Chest pain can occur in various cardiac conditions but is not a hallmark symptom of right-sided heart failure. It might be present if there are underlying coronary artery disease issues or other conditions, but it is not directly indicative of right-sided heart failure.
D. Peripheral edema is a classic finding in right-sided heart failure. It results from fluid accumulation in the lower extremities due to the heart's inability to effectively pump blood to the lungs and systemic circulation, causing increased venous pressure and fluid leakage into the tissues.
Correct Answer is B
Explanation
According to the recommended dosage range of 20 to 25 mg/kg/day for a toddler weighing 20 kg, the daily dosage should be between 400 mg (20 kg x 20 mg) and 500 mg (20 kg x 25 mg).
Therefore, the prescribed dosage of 300 mg per day is below the recommended range.
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