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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The pain can be severe and sudden at rest: This statement is more characteristic of unstable angina, where chest pain can occur at rest or with minimal exertion and is often severe and unpredictable.
B. The pain persists with rest and organic nitrates: This statement is more indicative of unstable angina or variant (Prinzmetal's) angina. Stable angina typically improves with rest and nitroglycerin (an organic nitrate).
C. The pain usually lasts longer than 20 minutes: Stable angina pain typically lasts for a few minutes (usually less than 5 to 10 minutes) and resolves with rest or nitroglycerin. Pain lasting longer than 20 minutes may indicate an acute coronary syndrome such as unstable angina or myocardial infarction.
D. Exertion and anxiety can trigger the pain: This statement is accurate for stable angina. Exertion, such as physical activity or emotional stress, can trigger anginal pain in individuals with stable angina due to increased oxygen demand by the heart.
Correct Answer is ["1712.32"]
Explanation
To calculate the client's total intake for the 8-hour shift, we need to convert all the volumes to milliliters (mL) and then add them together. Here are the given volumes and their conversions:
1,000 mL 0.9% sodium chloride IV (no conversion needed)
One 6-oz cup of coffee:
6 oz * 29.5735 (conversion factor for oz to mL) = approximately 177.44 mL
6 oz of water:
6 oz * 29.5735 = approximately 177.44 mL
One 180-mL bowl of soup (no conversion needed)
3 oz of flavored gelatin:
3 oz * 29.5735 = approximately 88.72 mL
3 oz of ice cream:
3 oz * 29.5735 = approximately 88.72 mL
Now, let's add up all the volumes:
1,000 mL (IV fluid) + 177.44 mL (coffee) + 177.44 mL (water) + 180 mL (soup) + 88.72 mL (gelatin) + 88.72 mL (ice cream) = 1,712.32 mL
Therefore, the nurse should document the client's total intake for the shift as approximately 1,712.32 mL.
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