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 D
Explanation
A. "I've been wearing the same few things every day because most of my clothes don't fit anymore." This statement reflects a common experience during pregnancy as the body changes. While it may indicate some frustration, it does not necessarily suggest difficulty accepting body image changes.
B. "Dressing up for work is a little harder now that I can't wear high heels." This statement acknowledges an adjustment in clothing choices due to pregnancy but does not indicate distress about body image. Many individuals modify their footwear for comfort and safety as pregnancy progresses.
C. "I've had to start wearing nursing bras already because my breasts are growing so much." This statement reflects awareness of bodily changes rather than difficulty accepting them. Breast enlargement is a normal part of pregnancy, and choosing appropriate clothing to accommodate these changes suggests adaptation rather than distress.
D. "When I wear high-top yoga pants, they hold my belly in so you can't even tell I'm pregnant." This statement suggests an attempt to conceal the pregnancy, which may indicate discomfort with body image changes. Actively trying to hide the pregnancy rather than embracing the natural progression of body changes can be a sign of difficulty accepting the physical transformation.
Correct Answer is B
Explanation
A. "Same-sex activity is less risky during pregnancy than male-female intercourse." Sexual activity of any kind can pose potential risks, such as vaginal irritation, pressure on the abdomen, or infection transmission if proper hygiene is not maintained. While pregnancy risks associated with semen exposure do not apply in a same-sex relationship, safety considerations remain important.
B. "There are some modifications that can increase the safety of sexual activity during your pregnancy." Sexual activity is generally safe during pregnancy, but adjustments may be necessary to ensure comfort and reduce potential risks. As the pregnancy progresses, certain positions may need to be changed to avoid pressure on the abdomen. If complications such as placenta previa or a history of preterm labor are present, additional precautions may be recommended.
C. "Most people find that pregnancy significantly decreases their desire for sexual activity." Sexual desire during pregnancy varies among individuals. Some may experience a decrease due to hormonal changes, nausea, or fatigue, while others may have an increased desire for sexual activity.
D. "Since you are monogamous there are no risks related to sexual activity during your pregnancy." A monogamous relationship reduces the risk of sexually transmitted infections but does not eliminate other potential concerns. Vaginal irritation, complications related to certain pregnancy conditions, or discomfort due to physical changes can still occur, making it important to discuss any concerns with a healthcare provider.
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