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 A
Explanation
The client has neutropenia, which is a low number of neutrophils, a type of white blood cell that fights infection. The client is at risk for developing infections from bacteria and fungi that are normally present in the environment. Raw fruits may contain these microorganisms and should be avoided.
Contact isolation is not necessary for neutropenic clients, unless they have an active infection. Applying pressure to venipuncture sites for 10 min is a standard precaution for all clients, not specific to neutropenic clients. Moving the client to a negative pressure room is indicated for clients with airborne infections, not neutropenic clients.
Correct Answer is B
Explanation
Palpating the dorsalis pedis pulse is an essential action to monitor for adequate circulation and perfusion in an extremity with an external fixator, which is a device that stabilizes and aligns fractured bones with metal pins and rods outside of the skin. The other options are incorrect because they could cause complications such as edema, infection, or malalignment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.