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 ["A","B","C","D","E","H","J"]
Explanation
- WBC count 6,700/mm³ is unchanged from previous readings, remaining within normal limits, indicating no new or worsening infection or inflammatory response.
- Hemoglobin 12 g/dL represents a significant increase from the previous value of 7.8 g/dL, demonstrating successful red blood cell transfusion and improvement in oxygen-carrying capacity.
- Hematocrit 36% is also markedly improved from 24%, further confirming correction of anemia following transfusion.
- Blood pressure 112/74 mm Hg has increased from a low of 76/45 mm Hg, indicating improved circulatory status and perfusion following fluid resuscitation and transfusion.
- Heart rate 95/min is a decrease from previous tachycardic values (121/min), suggesting stabilization of hemodynamics and resolution of compensatory response to anemia and hypotension.
- Oxygen saturation 100% on 2 L/min O₂ via nasal cannula confirms adequate oxygenation, demonstrating improved hemoglobin levels and effective oxygen delivery.
- Respiratory: bilateral breath sounds clear confirms stable respiratory function, showing no complications such as fluid overload or transfusion-related lung injury.
Correct Answer is B
Explanation
A. Believes that his brother's death will be reversible. This response is more typical of preschool-aged children (ages 3 to 5), who often perceive death as temporary or reversible, similar to sleep or separation. School-age children, however, begin to understand the finality of death, though they may still struggle with its implications.
B. Believes his bad behavior is causing his brother's death. School-age children (ages 6 to 12) often engage in magical thinking and may believe that their actions, thoughts, or behaviors are responsible for events, including illness and death. They may feel guilt and self-blame, thinking that past misbehavior contributed to their sibling's condition. Providing reassurance and education about the medical causes of the illness can help alleviate these feelings.
C. Alienates himself from his peers. While social withdrawal can occur in grieving children, school-age children typically seek peer support and may use friendships as a coping mechanism. Alienation is more commonly seen in adolescents, who might isolate themselves due to difficulty expressing emotions or fear of burdening others.
D. Regresses to an earlier developmental level. Regression, such as bedwetting, clinging behavior, or baby talk, is more commonly seen in younger children, particularly toddlers and preschoolers, when they experience stress or grief. School-age children are more likely to express distress through guilt, sadness, or behavioral changes rather than regression.
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