A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?

Check that the client has a small gauge IV catheter in place.

Check the blood product's compatibility with the client's blood type.

Prime the client's primary IV tubing with lactated Ringer's.

Confirm the identity of the client with the blood bank technician.

Answer and Explanation

The Correct Answer is B

A. Check that the client has a small gauge IV catheter in place.

Blood transfusions require a large-bore IV catheter (18-20 gauge) to prevent hemolysis and ensure efficient infusion. A small gauge IV (such as 22-24G) is not appropriate for PRBCs as it can slow the infusion and damage red blood cells.

B. Check the blood product's compatibility with the client's blood type: Before administering packed red blood cells (PRBCs), the nurse must verify blood compatibility to prevent a hemolytic transfusion reaction, which can be life-threatening.

C. Prime the client's primary IV tubing with lactated Ringer’s.

Only normal saline (0.9% NaCl) should be used to prime the IV tubing for a blood transfusion. Lactated Ringer’s and dextrose solutions can cause hemolysis and clotting of the blood product.

D. Confirm the identity of the client with the blood bank technician. While verifying the blood product is critical, the nurse should confirm the client’s identity at the bedside with another licensed nurse, not the blood bank technician. This ensures that the right blood is given to the right client following facility protocols.

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Correct Answer is B

Explanation

A. Gown:

After removing gloves, the gown should be taken off. The gown is considered the second most contaminated item. It is important to avoid contact with the outer surface of the gown while removing it.

B. Gloves:

Gloves should be removed first because they are the most likely part of the PPE to be contaminated. Care should be taken to avoid touching the outside of the gloves, and they should be disposed of properly.

C. Mask:

The mask is removed next. Care should be taken to handle the mask by the ties or ear loops without touching the front surface. Removing the mask last helps protect the nurse from potential respiratory droplets on the mask.

D. Eyewear/Face Shield:

Eyewear or face shield is removed last. Similar to the other components, it should be handled carefully to prevent self-contamination. This step helps protect the eyes and face from any potential splashes or airborne particles.

A. "You shouldn't worry about the future so you can concentrate on getting well." B. "if you work hard on your physical therapy, you won't need to worry." C. "You're concerned about what will happen when you leave the hospital?" D. "Why are you concerned even though everyone is here to help you?"

Correct Answer is C

Explanation

A. "You shouldn't worry about the future so you can concentrate on getting well.":

This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.

B. "If you work hard on your physical therapy, you won't need to worry.":

While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.

C. "You're concerned about what will happen when you leave the hospital?":

This response reflects active listening and empathy, acknowledging the client's expressed concern and inviting further discussion. It allows the client to express their feelings and concerns about the future, fostering a therapeutic nurse-client relationship.

D. "Why are you concerned even though everyone is here to help you?":

This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.

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A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?

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