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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While a slightly elevated hematocrit can be associated with dehydration, it's not as specific as urine specific gravity.
B. This indicates concentrated urine, which is a classic sign of dehydration. Normal urine specific gravity is typically between 1.005 and 1.030.
C. This is a normal creatinine level and does not indicate dehydration.
D. This is within the normal range for sodium.
Correct Answer is D
Explanation
A. While asking appropriate questions demonstrates that the partner is engaged and seeking understanding, it alone does not indicate that they are ready to perform the procedure independently.
B. Being able to verbalize all steps in the procedure shows that the partner has knowledge and understanding of the process. However, verbalizing alone does not confirm that they can perform the procedure accurately and safely. Practical skills and hands-on competence are crucial for readiness.
C. Attending a class provides important theoretical knowledge and information about tracheostomy care. However, attending a class by itself does not guarantee that the partner has developed the necessary skills to perform suctioning independently.
D. The ability to perform the procedure independently indicates that the partner has acquired the necessary skills and confidence to carry out suctioning safely and effectively. It shows practical proficiency, which is essential for readiness for discharge. The partner’s ability to perform suctioning without assistance demonstrates that they can handle the procedure in real-life situations.
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