A client with iron deficiency anemia is prescribed ferrous sulfate. Which instruction by the nurse is most appropriate to include in the client's teaching plan?

"Decrease intake of foods high in fiber as this medication may cause loose stools."

"Avoid consuming high in vitamin C within one hour of taking the medication."

"Stools may become darker in color while taking this medication."

"Take the medication on a full stomach for better absorption."

Answer and Explanation

The Correct Answer is C

A. Decreasing intake of foods high in fiber is not necessary; in fact, fiber can help prevent constipation, a common side effect of iron supplements.

B. Vitamin C actually enhances the absorption of iron; thus, avoiding it is incorrect. Clients should be encouraged to consume vitamin C alongside their iron supplements to improve absorption.

C. Stools becoming darker in color is a common and expected side effect of ferrous sulfate due to the presence of unabsorbed iron. It is important for clients to know this to avoid unnecessary alarm.

D. Taking the medication on a full stomach may decrease absorption; it is generally recommended to take iron supplements on an empty stomach for optimal absorption unless gastrointestinal upset occurs.

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Correct Answer is A

Explanation

A. Ensuring the blood is compatible with the client's blood type is critical in preventing an acute hemolytic reaction, as incompatible blood transfusions can cause serious, potentially life-threatening reactions.

B. Administering the transfusion rapidly can increase the risk of complications and does not prevent hemolytic reactions; transfusions should be given at a safe rate based on the client's condition.

C. Using a blood warmer is not a standard intervention to prevent hemolytic reactions; it's typically used in specific cases such as massive transfusions or hypothermia, but it does not address compatibility.

D. Administering prophylactic antihistamines is not a recommended practice to prevent hemolytic reactions; it is more relevant for preventing allergic reactions associated with transfusions.

A. Hang a bag of 0.9% normal saline with 5% dextrose at the bedside (D5%NS) B. Verify the client's name and blood type with a second nurse C. Infuse the unit of blood within 4 hours. D. Obtain baseline vital signs prior to starting the transfusion E. Continuously monitor the client during the first 15 minutes of the transfusion F. Insert an 18-gauge intravenous catheter G. Insert a 22-gauge intravenous catheter

Correct Answer is ["B","C","D","E","F"]

Explanation

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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A client with iron deficiency anemia is prescribed ferrous sulfate. Which instruction by the nurse is most appropriate to include in the client's teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

Correct Answer is A

Explanation

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

Correct Answer is ["B","C","D","E","F"]

Explanation

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