A nurse is preparing to administer a unit of packed RBCS to a client. Which of the following actions should the nurse plan to take?
Initiate venous access with a 21-gauge needle.
Use Y tubing with 0.9% sodium chloride when administering the transfusion.
Administer the unit of packed RBCs over 1 hr.
Obtain the client's first set of vital signs 1 hr after initiating the transfusion.
The Correct Answer is A
Practice standards indicate blood should be infused through a 20-gauge or larger catheter to prevent hemolysis [destruction] of red blood cells. Y tubing with 0.9% sodium chloride is used to administer blood products is not necessary. A unit of packed RBCs should be administered over 2 to 4 hours, unless otherwise ordered by the provider, to reduce the risk of fluid overload and transfusion reactions . The client's vital signs should be obtained before, during (15 minutes after starting and every hour thereafter), and after the transfusion to monitor for any signs of adverse reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Back pain is a common symptom of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks and destroys the donor's red blood cells. Other symptoms include fever, chills, dyspnea, chest pain, hypotension, tachycardia, hemoglobinuria, and jaundice. A hemolytic transfusion reaction is a medical emergency that requires immediate intervention.
Correct Answer is A
Explanation
The client who has an allergy to bananas may also have an allergy to latex, as they share some common proteins that can trigger an immune response. The nurse should avoid using latex gloves, catheters, syringes, or other products that may contain latex when caring for this client. The other options are not related to banana allergy.
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