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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A frozen fruit juice bar for dessert is a low-sodium option that can satisfy the client's sweet tooth. According to the National Health and Nutrition Examination Survey, Americans consume about 3700 mg of sodium daily, which is much higher than the recommended 2300 mg for the general population and 1500 mg for those with heart failure. Excessive sodium intake can lead to fluid retention, hypertension, and worsening of heart failure symptoms. Therefore, the client should avoid high-sodium foods such as vegetable juice, garlic and onion salts, and mayonnaise.

A. A client who has multiple sclerosis and reports ataxia and vertigo B. A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% C. A client who has left-sided paralysis and slurred speech from a prior stroke D. A client who has thrombocytopenia and reports a nosebleed

Correct Answer is D

Explanation

The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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