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. Lymphocytes are a type of white blood cell that plays a crucial role in the immune system, specifically in the response to infections and in immune regulation. They do not have a role in the transport of oxygen in the blood.
B. Neutrophils are another type of white blood cell that is essential for fighting bacterial infections. They are part of the body's immune response but do not transport oxygen.
C. Platelets are small cell fragments that are crucial for blood clotting and wound repair. They do not have a role in oxygen transport.
D. Hemoglobin is the primary molecule responsible for transporting oxygen in the blood. It is a protein found in red blood cells (erythrocytes) that binds to oxygen in the lungs and releases it in tissues throughout the body. Hemoglobin carries the majority of oxygen in the bloodstream and is essential for effective oxygen transport and delivery.
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.
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