The nurse reviews the entries in the medical record.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
Start an IV bolus of lactated Ringer's solution.
Stay with the client for the first 15 min of the transfusion.
Obtain the first unit of packed RBCs from the blood bank.
Document the blood product transfusion in the client's medical record.
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Indicated:
Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mmHg: - The client is hypotensive (76/45 mmHg), likely due to acute blood loss anemia from a gastrointestinal (GI) bleed. Adjusting the transfusion rate helps stabilize BP while preventing volume overload.
Stay with the client for the first 15 minutes of the transfusion: The highest risk of a transfusion reaction (e.g., hemolysis, anaphylaxis, febrile reaction) occurs within the first 15 minutes, so the nurse must remain with the client for close monitoring.
Obtain the first unit of packed RBCs from the blood bank: The client’s condition (hypotension, tachycardia, history of melena) suggests GI bleeding and significant blood loss. RBC transfusion is required to restore oxygen-carrying capacity and improve perfusion.
Document the blood product transfusion in the client’s medical records: Proper documentation includes blood product type, volume infused, time started and completed, client response, and any adverse reactions. This ensures compliance with safety protocols.
Not Indicated:
Start an IV bolus of lactated Ringer’s solution: Lactated Ringer’s (LR) is incompatible with blood products because it contains calcium, which can cause clotting in the IV line. Normal saline (0.9% NaCl) should be used instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Diazepam is a benzodiazepine medication commonly used to manage seizures, including those associated with alcohol withdrawal. It acts as a central nervous system depressant, reducing excessive neuronal activity and helping control seizures. Diazepam is considered the first-line medication for managing alcohol withdrawal seizures due to its efficacy and safety profile when administered under medical supervision.
Choice B rationale:
Naltrexone is an opioid receptor antagonist used primarily to treat alcohol and opioid dependence. It does not have a direct anticonvulsant effect and is not indicated for managing seizures associated with alcohol withdrawal. Naltrexone works by blocking the effects of opioids and reducing cravings, making it valuable in substance use disorder treatment but not in the acute management of seizures.
Choice C rationale:
Acamprosate is another medication used in the treatment of alcohol dependence. It helps maintain abstinence from alcohol by reducing cravings and withdrawal symptoms. However, it does not have anticonvulsant properties and is not used to manage seizures associated with alcohol withdrawal. Acamprosate is more focused on supporting long-term sobriety and preventing relapse in individuals
Correct Answer is ["B","D","E"]
Explanation
The nurse should discuss the following dietary recommendations with the client who has Crohn's disease:
Avoid eating fried, fatty foods and large meals: Fried and fatty foods can be difficult to digest and may worsen symptoms of diarrhea and abdominal pain. Consuming large meals can also put additional strain on the digestive system.
Limit high fiber foods, such as beans, popcorn, and seeds: High fiber foods can be challenging to digest and may exacerbate symptoms of Crohn's disease. Limiting these foods can help reduce gastrointestinal irritation and promote symptom relief.
Take a vitamin supplement daily with a meal: Crohn's disease can lead to nutrient deficiencies due to malabsorption. Taking a daily vitamin supplement with a meal can help ensure that the client receives essential nutrients and maintain overall nutritional status.
The following options are not appropriate dietary recommendations for a client with Crohn's disease:
- Drinking dairy and effervescent sodas for hydration: Dairy products can trigger symptoms in some individuals with Crohn's disease, especially if they have lactose intolerance. Effervescent sodas may contain carbonation and artificial sweeteners that can aggravate symptoms. Encouraging non-dairy sources of hydration, such as water or herbal teas, would be more appropriate.
- Enjoying fast food restaurants only if dining with friends: Fast food options are generally high in fat, sodium, and other additives that may worsen symptoms in individuals with Crohn's disease. It is advisable to limit or avoid fast food consumption altogether, regardless of whether dining alone or with others.
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