The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from a gastrointestinal hemorrhage. Which action can the nurse delegate to the nursing assistant (unlicensed assistive personnel)?

Monitor the patient for shortness of breath or chest pain during the transfusion

Obtain the patient's temperature and blood pressure before the transfusion

Double-check the product numbers on the PRBCs with the patient ID band

Answer and Explanation

The Correct Answer is B

Choice A reason: Monitoring the patient for shortness of breath or chest pain during the transfusion is a critical task that requires nursing judgment and immediate intervention if complications arise. It is not appropriate to delegate this task to unlicensed assistive personnel.

Choice B reason: Obtaining the patient's temperature and blood pressure before the transfusion is a task that can be safely delegated to nursing assistants. This task does not require the clinical judgment of a licensed nurse and is within the scope of practice for unlicensed assistive personnel.

Choice C reason: Double-checking the product numbers on the PRBCs with the patient ID band is a crucial safety step that must be performed by licensed nursing staff. This task ensures the correct blood product is given to the correct patient and involves verification that cannot be delegated to unlicensed personnel.

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Correct Answer is D

Explanation

Choice A reason: A hemoglobin level of 12.0 g/dL is slightly below the normal range for men but is not the most critical concern preoperatively. It indicates mild anemia, which should be monitored but does not present an immediate high risk.

Choice B reason: A serum creatinine level of 1.3 mg/dL is slightly elevated and indicates mild renal impairment. While this should be considered, it is not as immediately concerning as a significantly abnormal coagulation value.

Choice C reason: A Blood Urea Nitrogen (BUN) level of 24 mg/dL is slightly above normal, indicating some renal function impairment or dehydration. However, it does not pose the most significant immediate risk compared to a high INR value.

Choice D reason: An INR of 3.5 is significantly elevated and indicates a high risk of bleeding. For a surgical patient, this is the most concerning pre-op lab value because it suggests that the patient's blood is not clotting properly. This increases the risk of excessive bleeding during and after surgery, making it a priority to address before proceeding with the operation.

A. Contact the health care provider B. Recheck the pulse in another 30 minutes C. Measure the ankle-brachial index D. Administer an oral anticoagulant

Correct Answer is A

Explanation

Choice A reason: Contacting the health care provider is the most appropriate action because a change in the Doppler sound may indicate a potential complication, such as graft occlusion or compromised blood flow. Immediate assessment and intervention by the health care provider are essential to prevent further complications and ensure the patient's safety.

Choice B reason: Rechecking the pulse in another 30 minutes is not advisable in this situation because it could delay necessary medical intervention. Prompt communication with the health care provider is crucial to address the underlying issue and provide timely care.

Choice C reason: Measuring the ankle-brachial index can provide valuable information about blood flow in the lower extremities, but it is not the immediate priority when a significant change in the Doppler sound is detected. Contacting the health care provider for further assessment and instructions takes precedence.

Choice D reason: Administering an oral anticoagulant is not an appropriate action without the direct instruction from a health care provider. The nurse must first report the change in the Doppler sound to the provider and follow their specific orders regarding medication and treatment.

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The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from a gastrointestinal hemorrhage. Which action can the nurse delegate to the nursing assistant (unlicensed assistive personnel)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse provides postoperative care to a patient who underwent peripheral artery bypass surgery. Thirty minutes after the initial assessment, the nurse reassesses the patient and detects a change in the Doppler sound over a pulse. Which action should the nurse take?

Correct Answer is A

Explanation

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