A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?

Administer the transfusion through a 25-gauge saline lock.

Administer the plasma immediately after thawing.

Transfuse the plasma over 4 hr.

Hold the transfusion if the client is actively bleeding.

Answer and Explanation

The Correct Answer is B

A)   Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B)   Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C)   Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D)   Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.

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Correct Answer is D

Explanation

A. While pain assessment is important, ensuring airway patency takes priority over pain assessment in a client who has received sedation.
B. Monitoring temperature is important but is not the priority in this scenario.

C. Warmth of extremities is not as critical as assessing the airway.

D. Gag reflex assessment is essential to evaluate the client's ability to protect their airway and prevent aspiration, especially after receiving sedation.

Correct Answer is []

Explanation

Nurses' Notes

1000:

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of

0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs

and bacon like I do every morning." Client is diaphoretic and short of breath. Heart

rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs

clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.

Rationale:

The symptoms of chest tightness radiating to the left arm, along with nausea, diaphoresis (sweating), shortness of breath, and an irregular, tachycardic (fast) heart rate are classic signs of a myocardial infarction. The faint pulses in myocardial infarction, can be caused by a reduced blood flow to the heart muscle due to a blockage of a coronary artery. The reduced blood flow result in a cool skin.

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A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?

Correct Answer is D

Explanation

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Correct Answer is []

Explanation

Nurses' Notes

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