A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

Check and document the client's vital signs

Ensure that the client's IV site uses a 22-gauge needle

Verify that the blood type and Rh of the packed RBCs are checked by two nurses

Obtain a bag of lactated Ringer's IV solution

Provide the RN with tubing that has a filter

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Checking and documenting the client's vital signs is a correct action, because it provides a baseline for comparison and helps to monitor for any signs of adverse reactions to the transfusion.

Choice B reason: Ensuring that the client's IV site uses a 22-gauge needle is an incorrect action, because a larger gauge needle (18- or 20-gauge) is preferred for blood transfusions to prevent hemolysis of the RBCs.

Choice C reason: Verifying that the blood type and Rh of the packed RBCs are checked by two nurses is a correct action, because it is a standard safety procedure to prevent transfusion errors and ensure compatibility.

Choice D reason: Obtaining a bag of lactated Ringer's IV solution is an incorrect action, because only normal saline (0.9% sodium chloride) should be used as the IV solution for blood transfusions. Other solutions may cause hemolysis or clotting of the blood.

Choice E reason: Providing the RN with tubing that has a filter is a correct action, because a filter is required for blood transfusions to remove any clumps or debris from the blood.

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Correct Answer is A

Explanation

Choice A reason:Option Ais correct. NSAIDs like ibuprofen arecommonly prescribedfor SLE-related joint pain and inflammation, provided there are no contraindications (e.g., renal impairment). The client’s statement reflects appropriate understanding of symptom management.

Choice B reason: This is an incorrect statement, because SLE is a systemic autoimmune disease that can affect multiple organs and tissues, not just the skin. The client may experience symptoms such as rash, arthritis, nephritis, anemia, or pericarditis.

Choice C reason:Option Cis incorrect. SLE patients requirerigorous sun protection(SPF ≥30) to prevent UV-induced flares. SPF 15 is insufficient, indicating inadequate teaching.

Choice D reason: This is an incorrect statement, because a mild fever can indicate an infection or a flare-up of SLE, which can require medical intervention. The client should monitor the temperature and report any fever or signs of infection to the provider.

A. I will use a soft toothbrush or foam swab for oral care. B. I will cleanse my mouth after meals with an alcohol-based mouthwash. C. I will use a straw when I drink liquids. D. I will rinse my mouth frequently with a hydrogen peroxide solution.

Correct Answer is C

Explanation

Choice A reason: This is a correct statement, because using a soft toothbrush or foam swab for oral care can help prevent trauma and irritation to the mucous membranes of the mouth, which are inflamed and ulcerated due to stomatitis. The client should brush the teeth gently and avoid using dental floss.

Choice B reason: This is an incorrect statement, because using an alcohol-based mouthwash can cause burning, drying, and further damage to the mucous membranes of the mouth, which are already compromised by stomatitis. The client should avoid using any mouthwash that contains alcohol, menthol, or other harsh ingredients.

Choice C reason: This is a correct statement, because using a straw when drinking liquids can help reduce the contact and friction of the fluids with the mouth sores, which can cause pain and discomfort. The client should drink plenty of fluids to prevent dehydration and maintain hydration.

Choice D reason: This is a correct statement, because rinsing the mouth frequently with a hydrogen peroxide solution can help cleanse and disinfect the mouth, and promote healing of the mouth sores. The client should dilute the hydrogen peroxide with water and rinse the mouth at least four times a day, or as prescribed by the provider.

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A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

Nursing Test Bank

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