A nurse is preparing to administer an infusion of packed RBCs through a peripheral IV catheter. Which of the following actions should the nurse take?
Prime the IV tubing with lactated Ringer's.
Use a 24-gauge IV catheter for the transfusion.
Ensure that the IV tubing has an in-line filter.
Prepare to change the tubing at least every 2 hr.
The Correct Answer is C
A. Prime the IV tubing with lactated Ringer's. Blood products should only be primed with 0.9% sodium chloride (normal saline) because other solutions (e.g., lactated Ringer's or dextrose solutions) can cause hemolysis.
B. Use a 24-gauge IV catheter for the transfusion. A 24-gauge catheter is too small for a blood transfusion and may cause hemolysis or slow infusion. A large-bore catheter (18–20 gauge) is recommended for optimal flow.
C. Ensure that the IV tubing has an in-line filter. An in-line filter helps remove clots and debris, reducing the risk of transfusion reactions.
D. Prepare to change the tubing at least every 2 hr. Blood tubing should typically be changed after 4 hours or after two units of blood, whichever comes first, to prevent bacterial contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A community health nurse can provide education, medication management, and health monitoring, but they do not specifically focus on ADL assistance.
B. Respite care provides temporary relief for caregivers, but it does not directly help the client develop skills to maintain independence.
C. A dietitian focuses on nutritional needs and meal planning, but this does not directly address the increased difficulty with ADLs.
Correct Answer is C
Explanation
A. Temperature of 38° C (100.4° F) A slight fever is not a primary sign of internal bleeding. It could be related to infection or another inflammatory response.
B. Respiratory rate of 10/min Internal bleeding is more likely to cause an increased respiratory rate (tachypnea) due to hypoxia rather than a decreased rate.
C. Heart rate of 112/min Tachycardia (HR >100 bpm) is an early sign of internal bleeding. The body increases the heart rate to compensate for blood loss and maintain perfusion.
D. Blood pressure of 136/88 mm Hg While low blood pressure (hypotension) can indicate severe internal bleeding, this BP is within normal range. However, a sudden drop in BP later would be a concerning sign.
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