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 A
Explanation
A. Covering the bowel with a sterile saline dressing helps keep the bowel moist and prevents infection.
B. Raising the patient to a high Fowler's position can increase abdominal pressure and worsen the evisceration.
C. Calling the RN is important, but the immediate priority is to protect the protruding bowel.
D. Turning the patient to the side is not appropriate and does not address the immediate need to protect the bowel.
Correct Answer is C
Explanation
Rationale:
A. The deltoid muscle is not recommended for IM injections in infants due to its small size.
B. The gluteus is not preferred due to the risk of hitting the sciatic nerve and because the muscle is not well-developed in infants.
C. The vastus lateralis muscle is the preferred site for IM injections in infants due to its size and low risk of complications.
D. "Upper thigh" is a vague term but typically refers to the vastus lateralis in the context of infant injections.
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