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 A

Explanation

The nurse should hang the drainage bag below the level of the client's abdomen to facilitate gravity drainage of fluid and waste products from the peritoneal cavity. The other options are incorrect because they may cause discomfort, infection, or inadequate dialysis.

A. Lithium B. Regular insulin C. Furosemide D. Desmopressin

Correct Answer is D

Explanation

Desmopressin is a synthetic form of antidiuretic hormone (ADH), which regulates water balance in the body. Diabetes insipidus is a condition caused by a deficiency or resistance to ADH, resulting in excessive urination and thirst. Desmopressin helps reduce urine output and prevent dehydration by mimicking the action of ADH on the kidneys. Lithium is a mood stabilizer that can cause nephrogenic diabetes insipidus by interfering with the response of the kidneys to ADH. Regular insulin is used to treat diabetes mellitus, not diabetes insipidus, as it lowers blood glucose levels by facilitating its uptake into cells.

Furosemide is a diuretic that increases urine output and can worsen dehydration in clients with diabetes insipidus.

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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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Correct Answer is D

Explanation

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