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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?

A.

Prime the IV tubing with lactated Ringer's.

B.

Use a 24-gauge IV catheter for the transfusion.

C.

Ensure that the IV tubing has an in-line filter.

D.

Prepare to change the tubing at least every 2 hr.

Answer and Explanation

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.


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

After providing perineal care and donning sterile gloves, the nurse should first lubricate the catheter tip followed by insert the catheter until urine flows.

Rationale:

  1. Lubricating the catheter tip ensures smooth insertion and minimizes discomfort or trauma to the urethra.
  2. Inserting the catheter until urine flows confirms proper placement before advancing slightly more to ensure complete drainage.

Correct Answer is C

Explanation

A. Flush the client's tube with 5 mL of water. – This is incorrect because the standard amount of water used to flush a feeding tube is typically 30–50 mL to maintain patency and prevent clogging.
B. Place the client in a supine position. – This is incorrect because the client should be placed in a semi-Fowler’s or Fowler’s position (at least 30–45 degrees) to reduce the risk of aspiration.
C. Check the pH level of the client's gastric contents. – This is the correct answer. Checking the pH of gastric contents (typically ≤5.5) helps confirm proper tube placement before administering feedings, reducing the risk of aspiration.
D. Check the patency of the client's tube every 8 hr. – This is incorrect because tube patency should be checked before each feeding or medication administration, not just every 8 hours.

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