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 C
Explanation
This is because tight-fitting underwear can trap moisture and create a favorable environment for bacterial growth, which can increase the risk of urinary tract infections (UTIs) . Loose-fitting underwear can allow air circulation and prevent moisture accumulation .
Choice A is wrong because drinking four 240 mL (8 oz) glasses of water each day is not enough to prevent UTIs. The recommended amount of water intake for adults is about 2 to 3 liters per day . Drinking enough water can help flush out bacteria from the urinary tract and prevent them from adhering to the bladder wall .
Choice B is wrong because voiding every 5 to 6 hours during the day is too infrequent and can increase the risk of UTIs. The nurse should advise the client to void every 2 to 3 hours during the day. This can help prevent urinary stasis and bacterial multiplication in the bladder .
Choice D is wrong because taking a bubble bath after intercourse can increase the risk of UTIs. The nurse should instruct the client to avoid bubble baths, vaginal douches, or sprays, as they can irritate the urethra and introduce bacteria into the urinary tract . The nurse should also advise the client to empty the bladder before and after sexual intercourse, as this can help remove bacteria that may have entered the urethra during sexual activity .
Correct Answer is C
Explanation
This is because varicella, or chickenpox, is a highly contagious disease caused by the varicella- zoster virus (VZV), which can spread through the air or by direct contact with the fluid from the blisters. A negative air pressure room prevents the air from the room from circulating to other areas of the hospital, reducing the risk of transmission to other patients and staff.
Choice A is wrong because aspirin should not be given to children with chickenpox, as it can cause a serious condition called Reye’s syndrome, which affects the brain and liver. Instead, acetaminophen can be used to reduce fever.
Choice B is wrong because droplet precautions are not enough to prevent the spread of chickenpox. Droplet precautions involve wearing a mask and gloves when in close contact with the patient, but they do not prevent the virus from traveling through the air. Airborne precautions, which include a negative air pressure room and wearing a respirator, are needed for chickenpox.
Choice D is wrong because Koplik spots are not a sign of chickenpox, but of measles, another viral infection that causes a rash. Chickenpox causes an itchy rash with small, fluid-filled blisters that crust over.
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