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 D
Explanation
A. Take the iron with dairy products to enhance absorption: This statement is incorrect. Calcium-rich foods, such as dairy products, can inhibit iron absorption. It's recommended to take iron supplements with vitamin C-rich foods or beverages to enhance iron absorption.
B. Limit foods high in fiber due to the risk for diarrhea: While some individuals may experience gastrointestinal side effects such as constipation or diarrhea when taking iron supplements, it is not generally recommended to limit foods high in fiber. Adequate fiber intake is important for overall digestive health.
C. Increase the intake of vitamin E to enhance absorption: Vitamin E does not directly enhance iron absorption. Vitamin C is the nutrient that enhances iron absorption, so increasing intake of vitamin C-rich foods or taking vitamin C supplements along with iron supplements can improve iron absorption.
D. Iron will cause the stools to darken in color: This statement is correct. Iron supplements can cause stools to become dark or even black in color. This is a harmless side effect known as "iron stools" and is caused by the reaction of iron with substances in the digestive tract.
Correct Answer is D
Explanation
A. The pain can be severe and sudden at rest: This statement is more characteristic of unstable angina, where chest pain can occur at rest or with minimal exertion and is often severe and unpredictable.
B. The pain persists with rest and organic nitrates: This statement is more indicative of unstable angina or variant (Prinzmetal's) angina. Stable angina typically improves with rest and nitroglycerin (an organic nitrate).
C. The pain usually lasts longer than 20 minutes: Stable angina pain typically lasts for a few minutes (usually less than 5 to 10 minutes) and resolves with rest or nitroglycerin. Pain lasting longer than 20 minutes may indicate an acute coronary syndrome such as unstable angina or myocardial infarction.
D. Exertion and anxiety can trigger the pain: This statement is accurate for stable angina. Exertion, such as physical activity or emotional stress, can trigger anginal pain in individuals with stable angina due to increased oxygen demand by the heart.
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