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 D

Explanation

The priority intervention for the nurse is to determine whether the client has an allergy to local anesthetics, as this could cause a serious adverse reaction during the procedure.

Thoracentesis is a minimally invasive procedure that involves inserting a needle into the pleural space to drain excess fluid or air from around the lungs. The procedure requires local anesthesia to numb the area where the needle is inserted. Therefore, it is essential to assess for any allergy to local anesthetics before proceeding with the procedure.

A. Administer 0.9% sodium chloride. B. Initiate a continuous IV insulin infusion. C. Begin bicarbonate continuous IV infusion. D. Check potassium levels.

Correct Answer is B

Explanation

The priority intervention for a client in DKA is to initiate a continuous IV insulin infusion to lower the blood glucose level and reverse the ketosis. Insulin also helps to correct the electrolyte imbalance and acid-base imbalance in DKA.

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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

A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

Correct Answer is B

Explanation

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