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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer and explanation.
The correct answer is choice C, hypertension. Hypertension is a contraindication to living kidney donation because it can increase the risk of kidney disease and cardiovascular complications in the donor. Hypertension can also affect the quality and survival of the donated kidney in the recipient.
Therefore, a potential donor with uncontrolled or poorly controlled hypertension should not undergo nephrectomy.
Choice A, osteoarthritis, is not a contraindication to living kidney donation.
Osteoarthritis is a degenerative joint disease that does not affect the kidneys or the cardiovascular system.
It may cause pain and stiffness in the joints, but it can be managed with medications and physical therapy. A potential donor with osteoarthritis can donate a kidney if they have normal kidney function and no other medical problems.
Choice B, primary glaucoma, is not a contraindication to living kidney donation.
Primary glaucoma is a condition that causes increased pressure in the eye and can lead to vision loss if untreated.
It does not affect the kidneys or the cardiovascular system. A potential donor with primary glaucoma can donate a kidney if they have normal kidney function and no other medical problems.
Choice D, amputation, is not a contraindication to living kidney donation.
Amputation is the surgical removal of a limb or part of a limb due to injury, infection, or disease.
It does not affect the kidneys or the cardiovascular system. A potential donor with amputation can donate a kidney if they have normal kidney function and no other medical problems.
Normal ranges for blood pressure are less than 120/80 mmHg for systolic and diastolic pressure, respectively.
Normal ranges for kidney function are eGFR above 60 mL/min/1.73 m2 and albuminuria below 30 mg/g.
Correct Answer is D
Explanation
The correct answer is choice D. Minimize noise in the newborn’s environment.
This is because neonatal abstinence syndrome (NAS) is a condition that affects newborns who are exposed to opioids or other addictive substances in the womb. These substances can cause withdrawal symptoms in the newborns, such as excessive crying, tremors, vomiting, diarrhea, and seizures.
Minimizing noise and other stimuli can help calm the newborn and reduce stress.
Choice A is wrong because swaddling the newborn with his legs extended can increase muscle tension and discomfort. Swaddling should be done with the legs flexed and hips abducted to prevent hip dysplasia.
Choice B is wrong because administering naloxone to the newborn can cause severe withdrawal symptoms and respiratory depression. Naloxone is an opioid antagonist that reverses the effects of opioids, but it is not recommended for newborns with NAS unless they have life-threatening respiratory depression.
Choice C is wrong because maintaining eye contact with the newborn during feedings can overstimulate the newborn and cause agitation. Eye contact should be avoided or limited during feedings for newborns with NAS.
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