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
Wear a lead apron when providing client care. Internal radiation therapy (brachytherapy) is a type of treatment that uses a radioactive source placed inside or near the tumor . The nurse should wear a lead apron to protect themselves from exposure to radiation when caring for the client. The other actions are not appropriate for a client receiving internal radiation therapy.
Correct Answer is C
Explanation
The first action that the nurse should take is to collect information about the irritant that caused the injury, as this will help determine the appropriate treatment and duration of irrigation. Ocular irrigation is the process of flushing the eye with sterile fluid to remove foreign substances or chemicals.
Different types of chemicals may have different effects on the eye, such as acid burns, alkali burns, or organic solvents. Therefore, it is essential to identify the type and concentration of the chemical, as well as the time and duration of the exposure, before proceeding with the irrigation.
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