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.
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
A. This helps prevent air leaks and maintains the closed drainage system's function.
B. Looping the tubing on the client's is incorrect as it can lead to inaccurate drainage and measurement of the fluid.
C. Placing the drainage system above the level of the client's heart is incorrect as it can lead to inaccurate drainage and measurement of the fluid.
D. Routine stripping of the chest tube is also not recommended as it can cause trauma to the pleura and potentially lead to complications.
Correct Answer is B
Explanation
A. Administering preoperative medications is a nursing responsibility but not directly related to informed consent.
B. Witnessing the patient's signature is the nurse's primary responsibility regarding informed consent in the preoperative period. This verifies that the patient understands the procedure and voluntarily agrees to it.
C. Explaining the surgical procedure is the responsibility of the surgeon or physician.
D. Monitoring vital signs is a postoperative responsibility.
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