A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take?

Check the unit of blood with an assistant personal (AP).

Plan to infuse the unit of blood over 6 hr.

Remain with the client for the first 15 minutes of the transfusion.

Pre-medicate the client with an antiemetic.

Answer and Explanation

The Correct Answer is C

A. The blood must be checked by two licensed professionals, not an assistant personal (AP).
B. Blood should be infused within 4 hours to reduce the risk of bacterial contamination.
C. The nurse should remain with the client for the first 15 minutes of the transfusion to monitor for any immediate adverse reactions.
D. Pre-medicating with an antiemetic is not a standard practice unless specifically indicated by the client's history or condition.

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Correct Answer is C

Explanation

A. Endotracheal intubation might be necessary in severe cases of respiratory depression, but it is not the first step in addressing opioid overdose.
B. Protamine sulfate is the antidote for heparin, not morphine.
C. Naloxone (Narcan) is an opioid antagonist that can rapidly reverse the effects of opioid overdose, including respiratory depression.
D. Administration of oxygen is supportive care but does not address the root cause of opioid overdose.

A. Inform the client that this drug combination is most effective if the ginkgo biloba is taken twice daily. B. Inform the client that memory problems following valve replacement surgery are common, but temporary. C. Instruct the client that ginkgo biloba interacts with anticoagulant drugs and then check for bruising or bleeding. D. Instruct the client to keep a record of episodes of forgetfulness or memory disturbances to monitor effectiveness.

Correct Answer is C

Explanation

A. Advising a specific dosing regimen for ginkgo biloba without addressing safety concerns is not appropriate.
B. While memory problems may occur post-surgery, addressing the interaction between ginkgo biloba and warfarin is more urgent.
C. Ginkgo biloba can interact with anticoagulant drugs like warfarin, increasing the risk of bleeding. The nurse should instruct the client about this interaction and check for signs of bruising or bleeding.
D. Keeping a record of memory disturbances does not address the immediate safety concern of the interaction between ginkgo biloba and warfarin.

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A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

The nurse accidentally administers 15 mg of morphine IM to a client who had been given another dose of morphine 15 mg IM about 30 minutes earlier. What action should the nurse be prepared to take?

Correct Answer is C

Explanation

A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

Correct Answer is C

Explanation

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