nurse is caring for an adult client who has chronic anaemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
Set the IV infusion pump to administer the blood over 6 hr.
Administer the blood via a 21-gauge IV needle.
Check the client's vital signs from the previous shift prior to the initiation of the transfusion
Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
The Correct Answer is D
Choice A reason
Setting the IV infusion pump to administer the blood over 6 hours is not the recommended rate for administering packed RBCs. Blood transfusions are typically given more rapidly, usually within 2 to 4 hours. The specific rate may vary depending on the client's condition and the provider's order.
Choice B reason
Administering the blood via a 21-gauge IV needle is not typically related to the administration of the packed RBCs. The appropriate gauge of the IV needle for blood transfusions depends on the client's condition and the type of transfusion. Larger-gauge needles are often used for blood transfusions to allow for a faster flow rate and prevent haemolysis of the blood cells.
Choice C reason
Checking the client's vital signs from the previous shift prior to the initiation of the transfusion is not sufficient for ensuring the client's safety during the blood transfusion. The nurse should assess the client's current vital signs, including temperature, heart rate, blood pressure, and respiratory rate, before initiating the transfusion. Monitoring vital signs is essential during the transfusion to detect any adverse reactions or changes in the client's condition.
Choice D reason
Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion is the correct answer. When preparing to administer a blood transfusion to an adult client with chronic anaemia, the nurse should rush the blood administration tubing with 0.9% sodium chloride (normal saline) prior to the transfusion. This process is called priming the tubing.
Priming the tubing helps remove any residual air from the tubing and ensures that the blood transfusion is administered smoothly without introducing air into the client's bloodstream. Air embolisms can be a serious complication, and priming the tubing with normal saline helps prevent this risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is a flammable substance that can ignite in the presence of oxygen.
Using nail polish remover around the client can increase the risk of fire and burn injuries.
Choice A is wrong because synthetic fabrics can generate static electricity, which can also cause sparks and ignite oxygen.
The client’s bedding should be made of cotton or wool, which are natural fabrics that do not produce static electricity.
Choice B is wrong because petroleum jelly is a petroleum-based product that can react with oxygen and cause skin irritation or burns.
The client should use water-based moisturizers to soothe the mucous membranes.
Choice C is wrong because alcohol-based cleaning products are also flammable and can cause fires or explosions when exposed to oxygen.
The client should use mild soap and water to clean the equipment, and follow the manufacturer’s instructions for maintenance.
Some general safety tips for home oxygen therapy are:
- Keep away from heat and flame, such as candles, matches, lighters, stoves, fireplaces, etc.
- Do not smoke or allow others to smoke near the oxygen source
- Do not use aerosols, vapor rubs, oils, or other products that contain flammable substances near the oxygen source
- Store oxygen tanks or cylinders in a well-ventilated area away from direct sunlight and heat sources
- Secure oxygen tanks or cylinders to prevent them from falling or rolling
- Use the exact rate of oxygen prescribed by the doctor for each activity
- Check the oxygen gauge or level regularly and call the medical supply company when it is low
- Use a humidifier bottle if prescribed by the doctor to prevent dryness of the mucous membranes
- Change the nasal cannula, mask, and tubing as instructed by the medical supply company to prevent
Correct Answer is C
Explanation
The correct answer is C. FHR baseline 170/min. This is because a normal FHR baseline is between 110 and 160 bpm, and anything above or below this range indicates fetal distress and should be reported to the provider. A FHR baseline of 170/min could indicate fetal tachycardia, which could be caused by maternal fever, infection, dehydration, fetal anemia, or fetal hypoxia.
Choice A is wrong because early decelerations in the FHR are normal and benign, and indicate head compression during contractions.
They do not require any intervention or reporting.
Choice B is wrong because contractions lasting 80 seconds are within the normal range for active labor, which is 40 to 90 seconds per contraction.
They do not indicate any complication or abnormality.
Choice D is wrong because a temperature of 37.4° C (99.3° F) is slightly elevated but not considered a fever. A fever is defined as a temperature of 38° C (100.4° F) or higher.
A mild increase in temperature could be due to dehydration, exertion, or environmental factors, and does not necessarily indicate infection or inflammation.
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