The nurse reviews the entries in the medical record

Exhibits
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.

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Rationale:

A. "Your provider understands your illness and is acting according to your best interests.": This statement does not address the client’s concerns and may minimize their feelings. It shifts focus away from the client’s perspective rather than supporting their right to express concerns about discharge timing.

B. "I know you will be able to recover faster at home.": This statement assumes the provider’s decision is correct and discourages the client from expressing concerns. It does not advocate for the client or ensure their voice is heard in care planning.

C. "I will tell the provider about your concerns.": Communicating the client’s concerns to the provider demonstrates client advocacy. The nurse acts on behalf of the client to ensure their preferences, questions, and safety needs are considered in the discharge decision.

D. "I will contact your insurance company to see if they will pay for you to be here longer.": While insurance involvement may be relevant, the primary role of the nurse as an advocate is to convey the client’s concerns to the healthcare team rather than directly managing insurance coverage issues.

A. Pull the client's pinna down and back to apply the solution. B. Perform the procedure using sterile gloves. C. Administer the irrigation solution at room temperature to the ear D. Apply a stream of pressure as long as the client can tolerate.

Correct Answer is C

Explanation

Rationale:

A. Pull the client's pinna down and back to apply the solution.: Pulling the pinna down and back is the correct technique for infants and young children due to the angle of the ear canal. For adults, the pinna should be pulled up and back to straighten the ear canal. Using the incorrect direction can prevent proper visualization and reduce effectiveness of the irrigation.

B. Perform the procedure using sterile gloves.: Ear irrigation is a clean procedure, not a sterile one. The external ear canal is not a sterile environment, and using sterile gloves does not reduce infection risk. Clean gloves provide adequate protection while maintaining proper hygiene during cerumen removal.

C. Administer the irrigation solution at room temperature to the ear.: Using a solution at room temperature prevents stimulation of the vestibular system, which can cause dizziness, nausea, and vertigo. A temperature-neutral solution promotes client comfort and reduces physiologic irritation while effectively helping soften and remove cerumen.

D. Apply a stream of pressure as long as the client can tolerate.: Using forceful or prolonged pressure can damage the tympanic membrane or push cerumen deeper into the canal. Irrigation should be done gently, allowing the solution to flow along the canal wall and stopping immediately if the client reports pain or dizziness to avoid injury.

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The nurse reviews the entries in the medical record Exhibits 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who tells the nurse that he feels he is being discharged from the facility too soon. Which of the following statements by the nurse demonstrates client advocacy?

Correct Answer is C

Explanation

A nurse is preparing to irrigate an adult client's ear due to cerumen accumulation. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is providing preoperative teaching to a client about the administration of morphine via a PCA pump. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who received 50, 000 units of IV heparin rather than the prescribed 5,000 units. Which of the following actions should the nurse take first?

The nurse has reviewed the Nurses' Notes, Diagnostic Results, and Laboratory Results. Exhibits Select prescriptions the nurse should prescribe.

A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following actions should the nurse take? (Select all that apply)

A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care?

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

The nurse reviews the entries in the medical record

Exhibits
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.