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","C","D"]

Explanation

Choice A reason: Placing the client in a private room is a correct action, because it reduces the exposure of other clients and staff to the radiation source.

Choice B reason: Securing a dosimeter badge to the client's gown is an incorrect action, because the dosimeter badge is used to measure the radiation exposure of the staff, not the client. The client should wear an identification bracelet that indicates the type and location of the radiation source.

Choice C reason: Donning a cover gown before entering the client's room is a correct action, because it protects the nurse's clothing from contamination by the client's body fluids or secretions.

Choice D reason: Disposing of dislodged implants in a biohazard sharps container is a correct action, because it prevents the spread of radiation and infection. The nurse should also notify the radiation safety officer if an implant is dislodged.

A. Gown B. Gloves C. Mask D. Hair cover E. Goggles

Correct Answer is ["A","B"]

Explanation

Choice A reason: Wearing a gown is a correct action, because it protects the nurse's clothing and skin from exposure to the client's body fluids.

Choice B reason: Wearing gloves is a correct action, because it protects the nurse's hands from contact with the client's body fluids and reduces the risk of transmission of HIV.

Choice C reason: Not needed unless there's risk of respiratory exposure, which is not indicated here. AIDS is not spread via airborne particles.

Choice D reason: Wearing a hair cover is an incorrect action, because it is not necessary for standard precautions or contact precautions, which are the types of isolation required for a client who has AIDS and is incontinent of stool.

Choice E reason: Only needed if splashing of body fluids into the eyes is likely (not typical when simply changing linens).

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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

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has cancer and is scheduled to receive internal radiation therapy. Which of the following actions should the nurse recommend?

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is ["A","B"]

Explanation

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