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 B
Explanation
A. Cyanosis, a bluish discoloration of the skin, may be more visible in areas where the skin is thinner. The sacrum is not reliable especially in the dark colored individuals.
B. Palms of the hand is reliable site for assessing for cyanosis.
C. Incorrect. Shoulders are not a common location to assess for cyanosis. Areas with thinner skin, such as the lips, oral mucosa, and nail beds, are usually observed for cyanosis.
D. Incorrect. Areas of trauma are not specifically used to assess for cyanosis. Cyanosis is a clinical sign that indicates inadequate oxygenation of the blood.
Correct Answer is B
Explanation
Choice A rationale:
Looping the tubing so that it is lower than the collection bag creates a dependent loop where urine can pool, increasing the risk of UTI. This practice should be avoided as it can lead to bacterial contamination and subsequent infections.
Choice B rationale:
Keeping the urinary bag at bladder level when ambulating helps maintain a continuous flow of urine into the collection bag without creating dependent loops. This practice minimizes the risk of bacterial contamination and reduces the chances of acquiring a UTI.
Choice C rationale:
Obtaining urinary samples by disconnecting the tubing connections is not recommended. This procedure can introduce bacteria into the urinary system, increasing the risk of UTI. Sterile techniques, such as using a catheter port for sampling, should be followed to minimize the risk of infection.
Choice D rationale:
Securing the catheter to the client's thigh is essential to prevent tension and pulling on the catheter, which can cause trauma to the urethra. However, securing the catheter alone does not minimize the risk of UTI. Proper hygiene, closed drainage system, and maintaining a continuous flow of urine into the collection bag are key factors in preventing UTIs in clients with indwelling urinary catheters.
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