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. This is caused by an increase in acid or a loss of bicarbonate. Vomiting does not typically lead to this.
B. This is caused by a buildup of carbon dioxide in the blood, usually due to inadequate breathing.
C. This is caused by hyperventilation and excessive loss of carbon dioxide.
D. This is caused by a loss of acid or an increase in bicarbonate. Vomiting can lead to a loss of stomach acid, resulting in metabolic alkalosis.
Correct Answer is C
Explanation
A. Petroleum-based products should not be used in conjunction with oxygen therapy. They are flammable and can pose a fire hazard when used near oxygen. Instead, use water-based moisturizers to prevent dryness of the lips and skin.
B. Wool and other synthetic fabrics can generate static electricity, which is a fire hazard when using oxygen
therapy. It’s safer to use cotton blankets, as they are less likely to cause static buildup.
C. Oxygen tanks should be stored upright to prevent them from falling over and to ensure the regulator and valves are properly aligned. Storing tanks upright helps maintain stability and prevents accidental damage to the equipment.
D. While the recommendation to keep oxygen tanks away from electrical sources is important, the distance may vary based on specific guidelines. It is generally advised to keep oxygen tanks at least 5-10 feet away from electrical sources and heat sources to avoid any risk of ignition or fire.
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