The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

The transfusion will begin after the administration of 650 mg of acetaminophen {Tylenol).

The blood will be held, and the health care provider will be notified

The transfusion will begin after the administration of an antihistamine

The transfusion will begin as prescribed

Answer and Explanation

The Correct Answer is A

A. The transfusion will begin after the administration of 650 mg of acetaminophen (Tylenol).

This option suggests that the nurse would administer acetaminophen to lower the client's temperature and then proceed with the blood transfusion. While acetaminophen can be used to reduce fever, the decision to administer medication should be made by the healthcare provider after assessing the client's overall condition and determining the cause of the fever. Administering medication without proper evaluation and orders from the healthcare provider is not appropriate.

B. The blood will be held, and the health care provider will be notified.

This option is the correct choice. When a client has an elevated temperature before a blood transfusion, it is standard practice to hold the transfusion and notify the healthcare provider. An elevated temperature could indicate an underlying infection or another condition that needs to be evaluated before proceeding with the transfusion to ensure the client's safety.

C. The transfusion will begin after the administration of an antihistamine.

Administering an antihistamine would not be the appropriate action in response to an elevated temperature before a blood transfusion. Antihistamines are typically used to treat allergic reactions, not fevers. Holding the transfusion and notifying the healthcare provider to assess the situation would be the correct course of action.

D. The transfusion will begin as prescribed.

This option is not appropriate because starting the transfusion without addressing the elevated temperature could pose risks to the client's health. Elevated temperatures may indicate an underlying infection or other conditions that need to be evaluated before proceeding with the transfusion. Holding the transfusion and seeking further guidance from the healthcare provider is the recommended action in this scenario.

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Correct Answer is ["A","B","E"]

Explanation

A. Morbidly obese patient: Obesity is a known risk factor for VTE due to several reasons. Morbidly obese individuals often have impaired mobility, which can lead to venous stasis (sluggish blood flow in the veins). Additionally, obesity is associated with inflammation and changes in blood clotting factors, increasing the risk of developing blood clots in the veins.

B. A woman who smokes and takes oral contraceptives or smokes: Both smoking and oral contraceptive use are independent risk factors for VTE. Smoking can cause damage to blood vessels and alter blood clotting mechanisms, while oral contraceptives can increase the risk of blood clots due to hormonal changes.

C. Wheelchair-bound patient: While being wheelchair-bound alone may not always indicate a high risk for VTE, immobility is a significant risk factor for developing blood clots. Prolonged periods of immobility can lead to blood stasis in the veins, making wheelchair-bound patients susceptible to VTE, especially if other risk factors are present.

D. Patient with a humerus fracture: A humerus fracture on its own may not necessarily increase the risk of VTE significantly. However, if the fracture requires immobilization or surgery, especially if it affects the lower extremities or leads to prolonged immobility, the risk of VTE can increase due to decreased blood flow and stasis.

E. Patient who underwent a prolonged surgical procedure: Prolonged surgical procedures often involve anesthesia, immobility during surgery, and postoperative immobilization, all of which can contribute to venous stasis and increase the risk of developing VTE. Additionally, the surgical trauma itself can trigger inflammatory responses and alterations in blood clotting factors, further elevating the risk of blood clots.

A. Urine output is greater than 0.5 mL/kg/hr B. Serum hemoglobin is 11 gm/dL C. Breath sounds are clear bilaterally D. Heart rate is 122/min

Correct Answer is A

Explanation

A. Urine output is greater than 0.5 mL/kg/hr

During the fluid resuscitation phase of burn management, one of the primary goals is to maintain adequate tissue perfusion and organ function by ensuring sufficient fluid intake. The best method for assessing the results of fluid resuscitation is by monitoring urine output. A urine output of greater than 0.5 mL/kg/hr is indicative of adequate renal perfusion and kidney function, suggesting that fluid resuscitation is effective in maintaining tissue perfusion and preventing complications such as acute kidney injury.

B. Serum hemoglobin is 11 gm/dL

Serum hemoglobin levels can be affected by various factors, including fluid resuscitation, blood loss, and other medical conditions. While monitoring hemoglobin levels is important in overall patient assessment, it is not the best method specifically for assessing the results of fluid resuscitation during the initial phase of burn management.

C. Breath sounds are clear bilaterally

Clear bilateral breath sounds indicate adequate lung function and ventilation but may not directly reflect the effectiveness of fluid resuscitation in maintaining tissue perfusion. Lung sounds can be influenced by factors such as lung injury from smoke inhalation or mechanical ventilation settings, which may not correlate directly with fluid resuscitation outcomes.

D. Heart rate is 122/min

Heart rate can be influenced by various factors such as pain, stress, medications, and underlying medical conditions. While monitoring heart rate is important in assessing patient status, it is not the most reliable method for specifically evaluating the results of fluid resuscitation during the fluid resuscitation phase of burn management.

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The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse recently hired to the preoperative area learns that certain patients are at higher risk for venous thromboembolism (VTE). Which patients are considered to be at high risk? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is caring for a client during the fluid resuscitation phase of burn management. Which of the following is the best method for assessing the results of the fluid resuscitation?

Correct Answer is A

Explanation

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