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Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

Hang a bag of 0.9% normal saline with 5% dextrose at the bedside (D5%NS)

Verify the client's name and blood type with a second nurse

Infuse the unit of blood within 4 hours.

Obtain baseline vital signs prior to starting the transfusion

Continuously monitor the client during the first 15 minutes of the transfusion

Insert an 18-gauge intravenous catheter

Insert a 22-gauge intravenous catheter

Answer and Explanation

Correct Answer : B,C,D,E,F

A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.

B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.

C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.

D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.

E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.

F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.

G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.

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Correct Answer is B

Explanation

A. While legumes are a good source of protein, they do not provide the high-calorie density needed for someone experiencing wasting syndrome.

B. Consuming high-calorie snacks between meals is the most appropriate suggestion as it helps increase overall caloric intake, which is essential for clients with wasting syndrome to help maintain weight and improve nutritional status.

C. Using canola oil instead of butter may not significantly impact caloric intake, and clients with wasting syndrome may need higher-calorie options.

D. Adding celery to soups or salads adds volume but is low in calories and may not contribute significantly to the dietary needs of someone experiencing wasting syndrome.

A. Dietary iron restrictions B. Intestinal parasites C. Chronic bloody diarrhea D. Intestinal malabsorption syndrome

Correct Answer is C

Explanation

A. Dietary iron restrictions may affect iron intake, but they are not a direct symptom of ulcerative colitis that contributes to anemia.

B. Intestinal parasites can cause anemia but are not a common complication associated with ulcerative colitis.

C. Chronic bloody diarrhea is a significant symptom of ulcerative colitis and leads to iron loss and depletion, contributing to the development of anemia due to the loss of blood and iron.

D. Intestinal malabsorption syndrome can lead to anemia; however, it is not a primary symptom of ulcerative colitis itself, making chronic bloody diarrhea the more direct contributing factor.

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Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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