The nurse reviews the entries in the medical record
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.
Start an IV bolus of lactated Ringers solution.
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg 4
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Rationale:
• Stay with the client for the first 15 min of the transfusion: The first 15 minutes of a blood transfusion are critical for monitoring signs of a transfusion reaction, such as fever, chills, rash, or hypotension. Continuous observation allows the nurse to promptly intervene and prevent complications.
• Obtain the first unit of packed RBCs from the blood bank: Retrieving the blood from the blood bank ensures that the correct product is available for transfusion and meets safety protocols. Verification of type and crossmatch is essential before administration.
• Document the blood product transfusion in the client's medical record: Accurate documentation of the transfusion, including product type, volume, time, and client response, is required for legal, medical, and safety purposes. It ensures continuity of care and provides a record for any adverse events.
• Start an IV bolus of lactated Ringers solution: Routine IV bolus of lactated Ringer’s is not indicated unless the client has persistent hypotension requiring fluid resuscitation. Blood transfusion itself is the primary intervention to correct anemia in this client.
• Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: While monitoring blood pressure is important, adjusting the transfusion rate specifically to maintain a numeric BP is not standard practice. The transfusion rate should follow protocol, usually starting slow for the first 15 minutes and then adjusted per tolerance, not solely based on BP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. A client who moved to an apartment located on higher ground than her previous home: Relocating to a safer area demonstrates adaptive coping and proactive problem-solving. It does not indicate symptoms of posttraumatic stress disorder (PTSD) and does not require a referral for mental health assessment.
B. A client who has frequent nightmares about the hurricane: Recurrent intrusive thoughts or nightmares about a traumatic event are hallmark symptoms of PTSD. This client should be referred for further evaluation and possible treatment.
C. A client who expresses a realization that life will not return to the way it was before the hurricane: Accepting permanent changes after a disaster reflects normal adjustment and resilience. This insight alone does not suggest PTSD.
D. A client who describes feeling disconnected from those around him following the hurricane: Emotional numbing or detachment from others is a common PTSD symptom. This client should be referred for assessment to address potential social and emotional impairments.
E. A client who describes having persistent feelings of anger about the hurricane: Persistent irritability or anger is another symptom associated with PTSD. Referral is appropriate to evaluate for underlying trauma-related disorder and provide supportive interventions.
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Inability to concentrate: Hypoglycemia reduces glucose availability to the brain, leading to cognitive changes such as difficulty concentrating, confusion, or irritability. This neurologic symptom is an early and common indicator of low blood glucose.
B. Tremors: Trembling or shakiness occurs due to autonomic nervous system activation in response to low blood glucose. Catecholamine release stimulates muscle activity, making tremors a classic sign of hypoglycemia.
C. Acetone breath odor: Acetone or “fruity” breath is associated with diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. It indicates fat metabolism due to insulin deficiency, not low blood glucose.
D. Diaphoresis: Profuse sweating is a sympathetic nervous system response to hypoglycemia. It often accompanies other adrenergic symptoms such as palpitations, anxiety, and tremors, signaling low blood sugar.
E. Polydipsia: Excessive thirst is a symptom of hyperglycemia and is not associated with hypoglycemia. It occurs when high blood glucose leads to osmotic diuresis and fluid loss.
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