A nurse is preparing to administer 2 units of packed RBCs to a client.
Which of the following actions should the nurse take?
Transfuse each unit of blood over 5 hr.
Change the IV tubing after each unit of blood is transfused.
Prime the tubing with 0.9% sodium chloride.
Administer the blood through a 22-gauge intravenous catheter.
The Correct Answer is C
When administering packed RBCs, the tubing should be primed with 0.9% sodium chloride.
Transfusing each unit of blood over 5 hours (choice A) is not recommended as it may increase the risk of bacterial growth.
Packed RBCs should be transfused over 2 to 3 hours.
Changing the IV tubing after each unit of blood is transfused (choice B) is not necessary.
Administering the blood through a 22-gauge intravenous catheter (choice D) may not be appropriate as a larger gauge catheter is typically used for blood transfusions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The glycosylated hemoglobin level (also known as HbA1c or A1C) is a laboratory test that reflects average levels of blood glucose over the previous two to three months.
It is the most widely used test to monitor chronic glycemic management.
Choice A is not the answer because fasting blood glucose level reflects only short-term glycemic control.
Choice C is not the answer because oral glucose tolerance test results reflect only short-term glycemic control.
Choice D is not the answer because postprandial blood glucose level reflects only short-term glycemic control.
Correct Answer is A
Explanation
The correct answer is A. Back pain.
Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
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