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.
Stay with the client for the first 15 min of the transfusion.
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
Document the blood product transfusion in the client's medical record.
Obtain the first unit of packed RBCs from the blood bank.
Start an IV bolus of lactated Ringer's solution.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.
Explanation:.
- Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
- Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
- Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
- Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
- Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This method involves feeling the radial pulse while inflating and deflating the cuff.
The systolic pressure is estimated by noting the pressure at which the pulse disappears and reappears. The diastolic pressure is not measured by this method, but it can be useful when the sounds are difficult to hear.
Choice A is wrong because applying the largest cuff available can result in a falsely low reading. The cuff size should be appropriate for the client’s arm circumference.
Choice C is wrong because placing the arm above the level of the client’s heart can also cause a falsely low reading. The arm should be at the level of the heart for an accurate measurement.
Choice D is wrong because deflating the cuff quickly can lead to missing or skipping sounds, resulting in an inaccurate reading. The cuff should be deflated slowly and evenly.
Normal ranges for blood pressure vary depending on age, sex, and health conditions, but generally, a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg are considered normal for adults.
Correct Answer is C
Explanation
This is because potassium is a medication that can cause cardiac arrest if given too quickly or in high doses. A nurse who administers potassium via IV bolus is not providing the standard of care that a similarly trained nurse would have offered under the same circumstances. This could result in harm or death to the patient.
Choice A is wrong because placing a yellow bracelet on a client who is at risk for falls is not malpractice, but rather a safety measure.
A yellow bracelet indicates that the client needs assistance with mobility and should not be left alone. This is a common practice in many health care facilities to prevent falls and injuries.
Choice B is wrong because leaving a nasogastric tube clamped after administering oral medication is not malpractice, but rather a mistake.
A nasogastric tube is a tube that goes through the nose and into the stomach to deliver nutrition or medication.
It should be unclamped after giving oral medication to allow the medication to enter the stomach and prevent reflux or aspiration. However, this error does not rise to the level of malpractice unless it causes harm to the patient, such as vomiting, choking, or infection.
Choice D is wrong because documenting communication with a provider in the progress notes of the client’s medical record is not malpractice, but rather a good practice.
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