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 C
Explanation
A. Incorrect. Temporarily discontinuing the TPN infusion may result in an abrupt decrease in the client's glucose intake, which could lead to hypoglycemia.
B. Incorrect. Giving lactated Ringer's solution would not address the client's TPN needs and may also affect electrolyte balance.
C. Administering dextrose 10% in water wouldprovide the required glucosed as the next bag is awaited
D. Slowing the TPN infusion rate can help stretch the remaining volume until a new bag becomes available. However, it does not adress the body's glucose requirements.
Correct Answer is C
Explanation
The correct answer is a. Moving both crutches with the stronger leg forward first.
Rationale for Choice C:
- Proper positioning of the hands on the grips and keeping the elbows slightly flexed helps ensure stability and control while using the crutches.
Rationale for Other Choices:
a.In a three-point gait, the client moves both crutches and the affected leg together, followed by the unaffected leg. The stronger leg does not move forward first.
b. Stepping with the affected leg first when going up stairs: This action is incorrect for the three-point gait. When ascending stairs, the client should move the stronger leg up first, followed by the crutches and the affected leg.
d. Supporting his body weight while leaning on the axillary crutch pads: This action is also correct for general crutch use, but it does not specifically address the weight-bearing restrictions and movement pattern of the three-point gait.
Additional Information:
- Practice and supervision:It's essential for the client to practice the three-point gait under the supervision of a healthcare professional to ensure proper technique and safety.
- Gradual progression:The client should gradually increase their distance and duration of crutch use as their strength and coordination improve.
- Pain management:Adequate pain management is crucial to allow the client to participate in rehabilitation and regain mobility.
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