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 C
Explanation
Rationale:
A. Provide the child with electronics to watch movies: While distraction can be helpful in managing anxiety or discomfort, it does not directly address the child’s feelings about hair loss. Emotional support specific to the child’s concern is more appropriate in this situation.
B. Tell the child there's no need to cry because this is expected: Minimizing the child’s feelings invalidates their emotional experience and can increase distress. Acknowledging and supporting the child’s emotions is essential for coping during hair loss caused by radiation therapy.
C. Provide the child with a doll that does not have any hair: Giving a doll without hair helps the child normalize hair loss and provides a concrete way to express and cope with feelings. This action demonstrates understanding, empathy, and age-appropriate support for the child’s emotional needs.
D. Tell the child not to worry about their hair loss because their hair will grow back: While it is true that hair often regrows after treatment, reassurance alone does not address the child’s immediate emotional reaction. Supporting the child’s feelings and providing relatable coping strategies is more effective.
Correct Answer is ["B","C"]
Explanation
Rationale:
A. Respite care: Respite care provides temporary relief for caregivers, but it does not directly assist clients with limited financial resources in obtaining home IV therapy or covering medical costs. This resource may be helpful later but is not a primary financial support option.
B. Food stamps: Supplemental Nutrition Assistance Program (SNAP), or food stamps, helps low-income clients access adequate nutrition. Proper nutrition is important for healing and overall health, making this a relevant resource for a client below the poverty level.
C. Medicaid: Medicaid provides health coverage for low-income individuals and can help cover costs associated with home IV therapy, medications, and other healthcare needs. It is an appropriate recommendation for a client who meets income eligibility criteria.
D. Medicare Part A: Medicare primarily covers inpatient hospital care, skilled nursing facilities, hospice, and some home health services for clients over 65 or with certain disabilities. A young adult below the poverty level may not qualify, making this less appropriate for the scenario.
E. Adult day care: Adult day care provides socialization and supervision during the day, mainly for older adults or those with cognitive impairments. It does not address financial assistance or coverage for home IV therapy, so it is not a primary resource in this case.
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