The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client?
(Select All that Apply)
Administer each unit of blood over 34 hour
Anticipate an order for acetaminophen
Anticipate an order for furosemide administration
Assess for signs and symptoms of fluid overload
Anticipate administration of FFP for the next transfusion
Correct Answer : A,C,D
A. Administer each unit of blood over 3–4 hours
Older clients with CHF cannot tolerate rapid fluid shifts. Blood should be administered slowly (over 3–4 hours per unit) to prevent fluid overload.
B. Anticipate an order for acetaminophen
Acetaminophen is not routinely given before blood transfusions unless the client has a history of febrile reactions.
C. Anticipate an order for furosemide administration
Loop diuretics like furosemide may be ordered between units to prevent fluid overload in CHF patients.
D. Assess for signs and symptoms of fluid overload
CHF patients are at high risk for fluid overload, leading to dyspnea, crackles, and increased BP.
E. Anticipate administration of fresh frozen plasma (FFP) for the next transfusion
FFP is given for coagulation disorders, not for treating anemia in a GI bleed.
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Related Questions
Correct Answer is A
Explanation
A. Notify the physician and anticipate the need for endotracheal intubation
The client is showing progressive airway obstruction due to inhalation injury. The absence of wheezes indicates impending respiratory failure, requiring immediate airway management.
B. Place the client in semi-Fowler's position and administer an albuterol breathing treatment
Albuterol may help bronchospasm, but this client's issue is upper airway swelling, not bronchospasm. Intubation is the priority.
C. Encourage the client to cough, take deep breaths, and then auscultate again
The loss of wheezes suggests airway swelling has worsened, not that secretions are the issue. Immediate intervention is needed.
D. Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry
Guaifenesin and incentive spirometry help with secretion clearance, but they are not the priority in this emergent airway situation.
Correct Answer is B
Explanation
A. Provide the daughter and client with nutritional counseling.
While nutrition is important, assessing for abuse is the priority.
B. Interview the client alone and assess for abuse.
The client’s reluctance and daughter’s interruptions suggest potential elder abuse.
C. Take the history from the daughter due to the client’s confusion.
The client should be interviewed alone first.
D. Request a psychiatric evaluation.
Confusion can result from dehydration or trauma, not necessarily a psychiatric disorder.
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