The nurse is reviewing the client's medical record.
For each potential nursing action, click to specify if the action is indicated or not indicated.
Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above.
Start an IV bolus of lactated Ringer's solution.
Document the blood product transfusion in the client's medical record.
Discard the blood bag in the client's trash can after the transfusion.
Assist with obtaining the first unit of packed RBCs from the blood bank
Monitor the client for the first 15 min of the transfusion.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
- Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
- Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
- Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
- Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.
Not Indicated:
- Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
- Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Document the infiltration." While documentation is necessary, it is not the first action the nurse should take. Immediate intervention is required to prevent further complications from IV infiltration, such as tissue damage or fluid leakage into surrounding tissues.
B. "Stop the infusion." The first action the nurse should take is to stop the IV infusion to prevent further infiltration of fluid into the surrounding tissues. Continuing the infusion could worsen swelling, discomfort, and potential tissue injury.
C. "Elevate the arm." Elevating the affected extremity can help reduce swelling by promoting fluid reabsorption, but this should be done after stopping the infusion to prevent additional fluid from accumulating in the tissues.
D. "Apply a warm compress." A warm compress can help promote absorption of non-vesicant solutions, while a cold compress is preferred for certain medications to reduce swelling and pain. However, applying a compress should only be done after stopping the infusion and assessing the severity of infiltration.
Correct Answer is C
Explanation
A. Offer the client several choices at mealtimes. Clients with delirium often experience confusion and difficulty processing information. Providing too many choices can increase anxiety and agitation. Instead, offering simple and limited options helps reduce cognitive overload.
B. Alternate daily caregivers. Consistency in caregivers is important for clients with delirium to minimize confusion and distress. Frequent changes in caregivers can contribute to disorientation and make it more difficult for the client to feel secure.
C. Remind the client of the day and time often. Delirium is characterized by fluctuating levels of consciousness and confusion. Frequent orientation to time, place, and situation helps reduce anxiety and supports cognitive function. Using clocks, calendars, and familiar objects in the environment can reinforce orientation.
D. Avoid discussing the client's fears. Clients with delirium may have distressing thoughts or fears that should be acknowledged and addressed. Providing reassurance and a calm, supportive environment can help alleviate anxiety and improve the client's well-being.
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