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A nurse is planning to administer packed RBCs to an older adult client who has a low hemoglobin level.
Which of the following actions should the nurse plan to take?

A.

Hang the transfusion with dextrose 5% in 0.9% sodium chloride.

B.

Infuse the transfusion over 5 hr.

C.

Use a 20-gauge IV catheter to transfuse the blood.

D.

Monitor vital signs every hour throughout the transfusion.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Hanging the transfusion with dextrose 5% in 0.9% sodium chloride is incorrect. Packed red blood cells (PRBCs) are transfused with normal saline (0.9% sodium chloride) and not with dextrose-containing solutions. Using dextrose can cause the red blood cells to hemolyze.

Choice B rationale:

Infusing the transfusion over 5 hours is incorrect. PRBC transfusions are typically administered over 2-4 hours, not 5 hours. Infusing the blood too slowly may cause the patient discomfort and may also increase the risk of bacterial growth in the blood product.

Choice C rationale:

Using a 20-gauge IV catheter to transfuse the blood is incorrect. While a 20-gauge IV catheter is suitable for most blood transfusions, it may not be appropriate for older adults or patients with fragile veins. A smaller gauge, such as 22 or 24, might be more suitable to prevent phlebitis and ensure a steady flow without damaging the blood cells.

Choice D rationale:

Monitoring vital signs every hour throughout the transfusion is the correct action. During a blood transfusion, it's crucial to monitor the patient's vital signs frequently to detect any adverse reactions promptly. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, should be assessed before the transfusion, 15 minutes after starting the transfusion, and then hourly thereafter. This vigilant monitoring helps in identifying potential transfusion reactions, such as fever, chills, or hypotension, allowing for immediate intervention if needed.


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Related Questions

Correct Answer is B

Explanation

A is incorrect because documenting client tasks upon completion is an appropriate action by the newly licensed nurse that demonstrates accuracy and timeliness of documentation.

B is correct because starting a task then determining what supplies are needed is an inappropriate action by the newly licensed nurse that indicates poor planning and organization skills.

C is incorrect because completing a client assessment while infusing an IV antibiotic over 30 min is an appropriate action by the newly licensed nurse that demonstrates efficient use of time and multitasking ability.

D is incorrect because returning to the nurses' station after completing several tasks in the same location is an appropriate action by the newly licensed nurse that demonstrates effective prioritization and delegation skills.

Correct Answer is D

Explanation

Initiate transmission-based precautions.

Rationale:

  1. B- Encouraging oral fluids is an important intervention for a child who has a fever, as it helps prevent dehydration and electrolyte imbalance. However, it is not the priority intervention, as it does not address the risk of infection transmission to other clients or staff.
  2. A - Applying topical calamine lotion may help soothe the itching and discomfort caused by the vesicles, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
  3. C - Administering acetaminophen as an antipyretic may help reduce the fever and provide symptomatic relief for the child, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
  4. D - Initiating transmission-based precautions is the priority intervention, as it protects other clients and staff from exposure to the infectious agent that causes the vesicles and fever. The nurse should wear gloves, gown, mask, and eye protection when caring for the child, and place them in a private room or cohort them with other clients who have similar symptoms.

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