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.
Obtain the first unit of packed RBCs from the blood bank.
Start an IV bolus of lactated Ringer's solution.
Document the blood product transfusion in the client's medical record.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Rationale
1. Stay with the client for the first 15 minutes of the transfusion.
Indicated
This is a standard protocol for blood transfusions. The first 15 minutes of the transfusion are the most critical because acute transfusion reactions (such as allergic reactions, febrile reactions, or hemolysis) are most likely to occur during this time. By staying with the client, the nurse can monitor for any signs of reaction (e.g., fever, chills, shortness of breath, rash) and intervene immediately if necessary.
2. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
Indicated
Given the client’s low blood pressure (hypotension), it is important to monitor and potentially titrate the rate of infusion during the blood transfusion. The nurse should ensure that the blood pressure is maintained at an acceptable level. Blood transfusions can cause fluid shifts and affect hemodynamics, so the nurse may adjust the transfusion rate based on the client's vital signs to maintain adequate blood pressure and avoid complications, such as fluid overload or inadequate tissue perfusion.
3. Obtain the first unit of packed RBCs from the blood bank.
Indicated
The client is being prepared for a blood transfusion, so obtaining the blood product from the blood bank is a necessary step. The nurse must ensure that the correct blood product (two units of packed RBCs) is ordered, cross-matched, and ready for administration. Blood verification is critical to avoid transfusion errors, and this step is essential for the transfusion process.
4. Start an IV bolus of lactated Ringer's solution.
The provider’s prescription specifies a 500 mL bolus of normal saline (0.9% sodium chloride), not lactated Ringer's solution. Normal saline is preferred for blood transfusions because it does not contain calcium, which can bind to the citrate in blood products and cause clotting or other complications. Using the correct IV solution is essential for safety.
5. Document the blood product transfusion in the client's medical record.
Indicated
Proper documentation is essential in nursing practice. The nurse must record key information regarding the blood transfusion, including the type of blood product, the date and time of transfusion, the rate of infusion, and any reactions or complications. Documentation helps ensure continuity of care, and it is required by legal and institutional standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Supervising return demonstration is important but should occur after assessing the client's understanding of how to use the diaphragm.
B. Documenting the client's level of understanding is part of the assessment process but not the first step.
C. Teaching the client how to insert the diaphragm is important, but it should be done after determining
the client’s baseline knowledge.
D. Determining the client’s knowledge ensures that teaching is focused on areas where the client may need additional information.
Correct Answer is B
Explanation
A. Speaking slowly to the interpreter may cause delays in communication, but it does not enhance understanding. The interpreter is capable of processing normal speech speed.
B. The nurse should speak directly to the client, not the interpreter, to maintain rapport and respect. The interpreter will relay the information.
C. Pausing in the middle of sentences can disrupt the flow of conversation and make it harder for the interpreter to convey the message effectively.
D. Gestures should not be relied upon in place of clear verbal communication, as they can be misinterpreted and are culturally variable.
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