The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV ﬂuid should be used to initiate the IV for this transfusion?

100 mL of 5% dextrose and 1/2 normal saline

1,000 mL of lactated Ringer's solution

500 mL of 5% dextrose and water

250 mL of normal saline

Answer and Explanation

The Correct Answer is D

When collecting equipment to administer a unit of packed red blood cells, the nurse should use 250 mL of normal saline to initiate the IV for this transfusion ³. Normal saline is the only compatible solution to use with blood or blood components ³. The other options (100 mL of 5% dextrose and 1/2 normal saline, 1,000 mL of lactated Ringer's solution, and 500 mL of 5% dextrose and water) are not appropriate IV ﬂuids to use when administering a unit of packed red blood cells.

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Correct Answer is B

Explanation

When selecting interventions for a care plan, the nurse should consider several principles. One important principle is that actions should address the underlying cause (etiology) of the nursing diagnosis. By addressing the root cause of the problem, interventions can be more eﬀective in achieving the desired outcomes. There is not necessarily one "best" intervention for each goal or outcome, as diﬀerent clients may have diﬀerent needs and respond diﬀerently to interventions. Interventions can include both "doing" actions and monitoring, and both independent and collaborative interventions may be appropriate depending on the situation.

A. Document that the potential problem is being prevented from recurring. B. Document that the problem has been resolved and the goal has been met. C. Assume that whatever the cause was, the symptoms may return, but the goal was met. D. Keep the problem on the care plan in case the symptoms return.

Correct Answer is B

Explanation

The nursing diagnosis was "Risk for Deficient Fluid Volume" related to excessive ﬂuid loss, secondary to diarrhea and vomiting. The goal was set that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days, indicating that the problem has been resolved. Therefore, the nurse should document that the problem has been resolved and the goal has been met.

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The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV ﬂuid should be used to initiate the IV for this transfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following principles does the nurse use in selecting interventions for the care plan?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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