A charge nurse is precepting a newly licensed nurse who is to administer a transfusion of packed red blood cells (PRBC) to a client who has anemia. Which of the following actions by the new nurse should cause the charge nurse to intervene in this client's care immediately?
The nurse stays with the client for 15 minutes after beginning the transfusion.
The nurse primes the blood tubing with lactated ringers.
The nurse starts the infusion at a slow rate for the first 15 minutes.
The nurse witnesses the client sign the consent form for the blood transfusion.
The Correct Answer is B
A. The nurse stays with the client for 15 minutes after beginning the transfusion:
This action is appropriate as it ensures the nurse monitors the client closely for any immediate adverse reactions during the initial phase of the transfusion.
B. The nurse primes the blood tubing with lactated Ringer's solution:
This action is incorrect and potentially dangerous. Blood tubing should be primed with normal saline (0.9% sodium chloride) solution, not lactated Ringer's solution, to prevent potential adverse reactions or hemolysis of the blood products.
C. The nurse starts the infusion at a slow rate for the first 15 minutes:
This action is appropriate as it allows for the initial assessment of the client's tolerance to the transfusion and reduces the risk of adverse reactions.
D. The nurse witnesses the client sign the consent form for the blood transfusion:
This action is appropriate and ensures that the client has provided informed consent for the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1712.32"]
Explanation
To calculate the client's total intake for the 8-hour shift, we need to convert all the volumes to milliliters (mL) and then add them together. Here are the given volumes and their conversions:
1,000 mL 0.9% sodium chloride IV (no conversion needed)
One 6-oz cup of coffee:
6 oz * 29.5735 (conversion factor for oz to mL) = approximately 177.44 mL
6 oz of water:
6 oz * 29.5735 = approximately 177.44 mL
One 180-mL bowl of soup (no conversion needed)
3 oz of flavored gelatin:
3 oz * 29.5735 = approximately 88.72 mL
3 oz of ice cream:
3 oz * 29.5735 = approximately 88.72 mL
Now, let's add up all the volumes:
1,000 mL (IV fluid) + 177.44 mL (coffee) + 177.44 mL (water) + 180 mL (soup) + 88.72 mL (gelatin) + 88.72 mL (ice cream) = 1,712.32 mL
Therefore, the nurse should document the client's total intake for the shift as approximately 1,712.32 mL.
Correct Answer is ["125"]
Explanation
To calculate the infusion rate in mL/hr, you can use the formula:
Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)
In this case, the total volume is 1000 mL and the total time is 8 hours.
Infusion rate = 1000 mL / 8 hr
Infusion rate ≈ 125 mL/hr
The nurse should set the IV pump to deliver approximately 125 mL/hr.
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