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 B

Explanation

A. Enteral feeding, while important, can wait momentarily if the client's airway needs immediate attention.
B. Endotracheal suctioning is a priority if the client is having difficulty breathing or has excessive secretions in the airway.
C. Wound irrigation can be performed after ensuring the client's airway is clear and stable.
D. Urinary catheter care is important but can be prioritized after addressing acute respiratory needs.

A. Inform the provider that the PCA is not providing adequate pain relief. B. Ask the provider for a prescription to decrease the continuous rate. C. Instruct the client to push the button more frequently. D. Instruct the client's caregiver to push the PCA button when the client is resting.

Correct Answer is C

Explanation

A. The nurse should not inform the provider that the PCA is not providing adequate pain relief, as this is not true based on the client's pain rating of 2 out of 10.
B. The nurse should not ask the provider for a prescription to decrease the continuous rate, as this may compromise the client's pain relief and comfort.
C. The client should be encouraged to use the PCA pump before the pain becomes severe, as this will provide better pain control and reduce the risk of side effects.
D. Instructing the caregiver to push the button without the client's request may lead to overmedication and potential respiratory depression.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?

Correct Answer is B

Explanation

A nurse is caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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