A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

When the client states he is ready to start the infusion

As soon as the nurse can prepare the client and the administration set

2 hours after obtaining blood from the blood bank

When the client has finished eating lunch

Answer and Explanation

The Correct Answer is B

A. When the client states he is ready to start the infusion:

While it's important to consider the client's readiness and cooperation, the timing of the infusion should not solely depend on the client's statement. The priority is to start the infusion promptly after receiving the packed red blood cells (PRBCs) from the blood bank to ensure their safety and effectiveness.

B. As soon as the nurse can prepare the client and the administration set:

This choice is the correct answer. After receiving the unit of PRBCs from the blood bank at 1130, the nurse should begin the infusion as soon as possible after preparing the client (ensuring the correct patient, verifying the blood type compatibility, obtaining informed consent, etc.) and the administration set (priming the IV tubing, checking for any leaks, etc.). Prompt administration helps prevent delays that could compromise the quality of the blood product.

C. 2 hours after obtaining blood from the blood bank:

Waiting for 2 hours before starting the infusion is too long and could exceed the recommended timeframe for administering PRBCs after obtaining them from the blood bank. Delaying the infusion for such an extended period could impact the viability and safety of the blood product.

D. When the client has finished eating lunch:

The timing of the client's meal is not a factor in determining when to start the infusion of PRBCs. While it's generally important for the client to have adequate nutrition and hydration, the priority is to administer the blood product promptly after preparation to ensure its efficacy and safety, rather than waiting for unrelated factors such as meal times.

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Correct Answer is C

Explanation

A. Ascending edema:

Ascending edema, also known as dependent edema, is typically associated with right-sided heart failure rather than left-sided heart failure. In right-sided heart failure, the heart's ability to pump blood to the lungs for oxygenation is compromised, leading to fluid backup in the systemic circulation. This fluid accumulates in the dependent areas of the body, such as the lower extremities (legs and ankles), causing swelling that can ascend upwards if left untreated. However, ascending edema is not a characteristic finding in left-sided heart failure, where pulmonary congestion and orthopnea are more common manifestations.

B. The client has no desire to eat:

While decreased appetite can occur in heart failure due to various factors such as fluid retention, abdominal bloating, or medication side effects, it is not a specific hallmark of left-sided heart failure. Symptoms such as fatigue, dyspnea (shortness of breath), orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (PND) are more commonly associated with left-sided heart failure. These symptoms result from the impaired function of the left ventricle, leading to pulmonary congestion and inadequate oxygenation.

C. The client sleeps on three pillows at night:

This choice is the correct answer. Sleeping on three pillows at night is a classic manifestation of orthopnea, a condition commonly seen in left-sided heart failure. Orthopnea refers to difficulty breathing while lying flat, which is alleviated by elevating the head and upper body with multiple pillows or sleeping in a semi-upright position. Orthopnea occurs due to the redistribution of fluid from the legs and lower body to the lungs when lying down, resulting in pulmonary congestion and respiratory distress.

D. The client has a five-pound weight gain:

Weight gain is a common symptom of fluid retention in heart failure; however, a specific weight gain of five pounds alone may not be indicative of left-sided heart failure without considering other clinical signs and symptoms. In heart failure, weight gain is often associated with fluid overload, which can lead to edema, dyspnea, orthopnea, and other signs of congestion. It's important to assess the client comprehensively for fluid status, including evaluating for edema, respiratory symptoms, and changes in weight over time, to determine the underlying cause of weight gain.

A. Relieve client symptoms B. Extend survival C. Improve functional status D. Prevent endocarditis E. Limit physical activity

Correct Answer is ["A","B","C"]

Explanation

A. Relieve client symptoms - Heart failure can cause symptoms like shortness of breath, fatigue, swelling (edema), and difficulty exercising. Relieving these symptoms is an important goal to improve the client's quality of life and overall well-being.

B. Extend survival - Heart failure is a chronic condition that can significantly impact life expectancy. One of the goals of care is to optimize management to extend the client's survival and reduce the risk of complications.

C. Improve functional status - Heart failure can limit a person's ability to perform daily activities and exercise. Improving functional status involves strategies such as medication management, lifestyle modifications, and cardiac rehabilitation to enhance the client's ability to engage in daily activities and maintain independence.

D. Prevent endocarditis - Endocarditis is an infection of the inner lining of the heart chambers and heart valves. While preventing infections is important for overall health, preventing endocarditis may not be directly related to the primary goals of heart failure management. However, maintaining good hygiene and avoiding infections can contribute to the overall well-being of the client.

E. Limit physical activity - This statement is incorrect in the context of heart failure management. Encouraging appropriate levels of physical activity is often part of heart failure care. Physical activity, when tailored to the individual's abilities and guided by healthcare professionals, can improve cardiovascular function, strengthen muscles, and enhance overall health outcomes in clients with heart failure.

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A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is ["A","B","C"]

Explanation

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