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

Weight gain 1.1 kg (2.4 lb) in 24 hours indicates fluid retention and possible volume overload, which can worsen kidney function and cause complications such as hypertension, pulmonary edema, and heart failure. The nurse should report this finding to the provider and monitor the client's vital signs, fluid intake and output, and electrolyte levels.

Creatinine 0.8 mL/dL is within the normal range for adults and does not indicate kidney impairment. Peripheral pulses 2+ bilaterally are normal and do not suggest any vascular problems. Urine specific gravity 1.045 is slightly high but not abnormal for a client with acute kidney failure, as it reflects the reduced ability of the kidneys to dilute urine.

A. "Why do you think your life is over?" B. "Would you like to meet with another client who is an amputee?" C. "Most people can adjust following this surgery." D. "You are upset. We can talk about this later."

Correct Answer is B

Explanation

Choice a.This response may come across as challenging or confrontational. While the nurse is asking for more information, the phrasing could inadvertently put the client on the defensive. It doesn't validate the client's feelings and may not encourage a productive dialogue.

Choice b. “Suggesting peer support or mentorship from someone who has gone through a similar experience could be beneficial in some situations, as it may help the client feel less isolated.
Choice c. “Most people can adjust following this surgery.” may be true, but it does not acknowledge the client’s individual experience and feelings. It may also sound dismissive or minimizing of the client’s challenges.
Choice d. “You are upset. We can talk about this later.” may be intended to give the client some space, but it does not convey empathy or support. It may also make the client feel rejected or ignored.

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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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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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