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
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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Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect action, because instructing the client to blink several times after instillation of the medication can cause the medication to drain out of the eye and reduce its effectiveness.
Choice B reason: This is a correct action, but not the best one. Asking the client to look straight ahead during instillation of the medication can help the nurse to aim the drop accurately and avoid touching the eye with the dropper.
Choice C reason: This is the best action, because applying pressure to the bridge of the nose after instillation of the medication can prevent the medication from entering the systemic circulation and causing adverse effects, such as bradycardia, hypotension, or bronchospasm.
Choice D reason: This is an incorrect action, because placing each drop of the medication directly on to the client's cornea can cause irritation, injury, or infection to the eye. The medication should be placed in the lower conjunctival sac of the eye.
Correct Answer is D
Explanation
Choice A reason: This is a dangerous action, because recapping the needle on the syringe can increase the risk of needlestick injuries and bloodborne infections.
Choice B reason: This is an unnecessary action, because the client may be able to self-administer insulin injections with proper education and supervision.
Choice C reason: This is an inappropriate action, because the syringe should not be disposed of in the bathroom trash can, which is not a safe or sanitary place for sharps waste.
Choice D reason: This is the correct action, because placing the syringe in a puncture-proof disposal container can prevent accidental injuries and infections, and comply with the local regulations for sharps disposal.
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