The nurse is monitoring a patient who is receiving a blood transfusion. The nurse identifies that the blood transfusion started over four hours ago. What intervention will the nurse implement next?

Increase the rate of the transfusion to complete it as quickly as possible.

Stop the transfusion immediately and document the amount infused.

Continue the transfusion and monitor vital signs every 15 minutes.

Continue the transfusion at the current rate until it is completed.

Answer and Explanation

The Correct Answer is B

Choice A reason: Increasing the rate of the transfusion to complete it as quickly as possible is not safe. Blood transfusions should be completed within four hours to prevent complications such as bacterial contamination and hemolysis.

Choice B reason: Stopping the transfusion immediately and documenting the amount infused is the appropriate intervention. Blood products that have been transfusing for more than four hours must be stopped to ensure patient safety and prevent adverse reactions. Documentation ensures that the healthcare team is aware of the situation and can take appropriate follow-up actions.

Choice C reason: Continuing the transfusion and monitoring vital signs every 15 minutes is not appropriate after the four-hour window has passed. The risk of complications increases with prolonged transfusion times.

Choice D reason: Continuing the transfusion at the current rate until it is completed is not safe. The transfusion must be stopped after four hours to prevent potential complications.

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Correct Answer is A

Explanation

Choice A reason: The lab results pH 7.48, PaCO2 30, HCO3 24 indicate respiratory alkalosis. Hyperventilation leads to excessive loss of carbon dioxide (PaCO2), resulting in an increase in pH (alkaline). This is consistent with pulmonary edema and hyperventilation due to heart failure.

Choice B reason: The lab results pH 7.41, PaCO2 45, HCO3 29 indicate a normal pH with compensated metabolic alkalosis. This is not consistent with hyperventilation in pulmonary edema.

Choice C reason: The lab results pH 7.31, PaCO2 34, HCO3 18 indicate metabolic acidosis with partial compensation. This is not typical for a patient with hyperventilation and pulmonary edema.

Choice D reason: The lab results pH 7.25, PaCO2 59, HCO3 30 indicate respiratory acidosis with partial compensation. This would be consistent with hypoventilation rather than hyperventilation.

A. Ondansetron on a PRN basis B. Vitamin B12 injections to prevent pernicious anemia C. Antidiarrheal medications 30 minutes before a meal D. Beta adrenergic blockers to reduce bowel motility

Correct Answer is A

Explanation

Choice A reason: Ondansetron is an antiemetic given to control nausea and vomiting, which are common symptoms in patients with inflammatory bowel disease, especially when they have a flare-up.

Choice B reason: Vitamin B12 injections are crucial for preventing pernicious anemia but are not specific treatments for acute management of inflammatory bowel disease symptoms.

Choice C reason: Antidiarrheal medications should be used cautiously in inflammatory bowel disease as they can worsen symptoms or lead to complications like toxic megacolon.

Choice D reason: Beta-adrenergic blockers are not used to reduce bowel motility and are not a part of the standard treatment regimen for inflammatory bowel disease.

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The nurse is monitoring a patient who is receiving a blood transfusion. The nurse identifies that the blood transfusion started over four hours ago. What intervention will the nurse implement next?

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Naxlex Comprehensive Predictor Exams

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