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: This is the correct imbalance, because respiratory alkalosis is a condition that occurs when the blood pH is high, the PaCO2 is low, and the HCO3 is normal or low. Respiratory alkalosis is caused by hyperventilation, which can result from anxiety, fever, pain, or mechanical ventilation.

Choice B reason: This is an incorrect imbalance, because metabolic acidosis is a condition that occurs when the blood pH is low, the PaCO2 is normal or low, and the HCO3 is low. Metabolic acidosis is caused by the accumulation of acids in the blood, which can result from diabetic ketoacidosis, renal failure, or lactic acidosis.

Choice C reason: This is an incorrect imbalance, because respiratory acidosis is a condition that occurs when the blood pH is low, the PaCO2 is high, and the HCO3 is normal or high. Respiratory acidosis is caused by hypoventilation, which can result from airway obstruction, chest injury, or narcotic overdose.

Choice D reason: This is an incorrect imbalance, because metabolic alkalosis is a condition that occurs when the blood pH is high, the PaCO2 is normal or high, and the HCO3 is high. Metabolic alkalosis is caused by the loss of acids from the blood, which can result from vomiting, gastric suction, or diuretic therapy.

A. Maintain the client's head of the bed at 20% B. Monitor the client’s blood glucose level C. Flush the enteral feeding tube with 10 mL of cool water after each medication D. Obtain an x-ray after beginning the feeding

Correct Answer is B

Explanation

Choice A reason: Maintaining the client's head of the bed at 20% is an incorrect action, because the head of the bed should be elevated at least 30% to prevent aspiration of the feeding.

Choice B reason: Monitoring the client’s blood glucose level is a correct action, because enteral feedings can affect the blood glucose level and the client may need insulin adjustments.

Choice C reason: Flushing the enteral feeding tube with 10 mL of cool water after each medication is an incorrect action, because cool water can cause cramping and nausea. The nurse should use warm water to flush the tube and use at least 30 mL of water to prevent clogging.

Choice D reason: Obtaining an x-ray after beginning the feeding is an incorrect action, because an x-ray should be obtained before starting the feeding to confirm the placement of the tube.

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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)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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