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 B

Explanation

The Ssegment is the portion of an electrocardiogram (ECG) that represents early ventricular repolarization, which occurs after ventricular contraction and before ventricular relaxation. The Ssegment can be elevated or depressed in cases ofmyocardial infarction (MI), indicating ischemia or injury to the myocardium due to reduced blood flow or oxygen supply.

A. Apply an ice pack to the client's knee. B. Place pillows under the client's knee. C. Gently massage the area around the client's incision. D. Perform range-of-motion exercises to the client's knee.

Correct Answer is A

Explanation

Applying an ice pack to the client's knee can help reduce inflammation, swelling, and pain after a total knee arthroplasty. The nurse should avoid placing pillows under the client's knee, as this can cause flexion contractures and impair mobility and healing. Massaging or manipulating the incision site can increase pain and risk of infection or bleeding. Range-of-motion exercises are important for recovery, but they should be done with caution and under supervision, not when the client is experiencing severe pain.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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