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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Medications should be diluted as per pharmacy recommendations, not arbitrarily with 10 mL of tap water.
B. The head of the bed should be elevated to at least 30-45 degrees during and after feeding to prevent aspiration.
C. Medications should not be mixed together to avoid interactions unless recommended by the pharmacy.
D. Flushing the NG feeding tube with 30 mL of water immediately following medication administration ensures that the medication has cleared the tube and prevents clogging.
Correct Answer is B
Explanation
A. While a high-calorie, high-protein diet is beneficial for wound healing, it is not the most critical factor in preventing further tissue damage.
B. Changing the patient's position every 2 hours is crucial to relieve pressure on the ulcer and prevent further tissue damage.
C. Changing the patient's linen daily is important for hygiene but does not directly prevent pressure ulcer progression.
D. Recording the size and appearance of the ulcer is important for monitoring, but preventing further damage through repositioning is more critical.
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