A nurse is caring for a client at risk for fluid volume overload with an order to infuse 1 unit of blood. The health care provider specified the rate of infusion must be 8 hours to prevent the effects of fluid volume overload in this client. Which intervention should the nurse implement for this client?

Retrieve the blood from the laboratory and run each unit at an 8-hour rate.

Notify the laboratory to split the unit into 2, then infuse each half for 4 hours.

Call the HCP to question the order because blood must infuse within 4 hours.

Infuse each unit for 8 hours, the maximum rate for a unit of blood.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Retrieving the blood from the laboratory and running each unit at an 8-hour rate is not appropriate. According to transfusion guidelines, blood products should be infused within 4 hours to prevent bacterial growth and reduce the risk of transfusion-related complications1. Infusing blood over 8 hours increases the risk of these complications.

Choice B Reason:

Notifying the laboratory to split the unit into 2 and then infusing each half for 4 hours is also not ideal. While this approach might seem to address the time constraint, it is not a standard practice and could lead to issues with blood product integrity and patient safety2. Blood products are typically not split unless there are specific protocols in place, and this is not a common intervention for managing infusion rates.

Choice C Reason:

Calling the HCP to question the order is the correct intervention. Blood transfusions must be completed within 4 hours to ensure patient safety and maintain the integrity of the blood product3. The nurse should advocate for the patient by questioning any orders that do not align with established guidelines and best practices.

Choice D Reason:

Infusing each unit for 8 hours is incorrect. The maximum duration for infusing a unit of blood is 4 hours4. Extending the infusion time beyond this limit increases the risk of complications such as bacterial contamination and reduced efficacy of the blood product.

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Correct Answer is D

Explanation

Choice A Reason:

“Records that the client sees the procedure as necessary” is incorrect. The nurse’s role in signing the consent form is not to document the client’s perception of the necessity of the procedure. This responsibility typically falls to the healthcare provider who explains the procedure and its necessity to the client.

Choice B Reason:

“Determines the client does not have a mental illness” is incorrect. While assessing the client’s mental status is part of the overall care, the nurse’s signature on the consent form does not specifically indicate this. The nurse’s role is to witness the client’s signature and ensure they are giving informed consent.

Choice C Reason:

“Assists that the nurse has explained the risks and benefits of the procedure” is incorrect. It is the responsibility of the healthcare provider performing the procedure to explain the risks and benefits. The nurse may reinforce this information but does not primarily provide it.

Choice D Reason:

“Confirms the client is competent to provide consent” is correct. The nurse’s signature on the consent form indicates that the nurse has witnessed the client signing the form and has verified that the client is competent to provide informed consent. This includes ensuring the client understands the information provided and is making the decision voluntarily.

A. Repeat auscultation after asking the client to take a deep breath and cough. B. Instruct the client to limit fluid intake to less than 2,000 mL/day. C. Place the client on bed rest in semi-Fowler’s position. D. Prepare to administer antibiotics.

Correct Answer is A

Explanation

Choice A Reason:

Repeating auscultation after asking the client to take a deep breath and cough is the first intervention the nurse should take. This action helps to clear any secretions or mucus that might be causing the crackles. If the crackles persist after the client coughs, it indicates that the sounds are likely due to fluid in the lungs, which requires further assessment and intervention. This step ensures that the nurse accurately identifies the cause of the crackles before proceeding with other interventions.

Choice B Reason:

Instructing the client to limit fluid intake to less than 2,000 mL/day might be appropriate in cases of fluid overload or heart failure, but it is not the first intervention. The nurse needs to confirm the cause of the crackles before making any recommendations about fluid intake. Limiting fluid intake without proper assessment could lead to dehydration and other complications.

Choice C Reason:

Placing the client on bed rest in semi-Fowler’s position can help improve lung expansion and oxygenation by reducing pressure on the diaphragm. However, this is not the first intervention. The nurse should first determine if the crackles are due to secretions that can be cleared by coughing. Semi-Fowler’s position is beneficial for patients with respiratory distress, but it does not address the immediate need to reassess lung sounds.

Choice D Reason:

Preparing to administer antibiotics is not the first intervention. Antibiotics are used to treat infections, and the nurse needs to confirm whether the crackles are due to an infection or another cause before administering medication. Immediate administration of antibiotics without proper assessment could lead to inappropriate treatment and antibiotic resistance.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client’s consent form. The nurse’s signature on the consent form indicates which of the following?

Correct Answer is D

Explanation

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which intervention should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client who had an arterial blood gas drawn. The pH on the ABG is 7.10. What acid-base imbalance does this client have?

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

A nurse is caring for a client diagnosed with end-stage liver cancer. Which response is an indication the client is in the denial phase of the grief process?

A nurse is caring for a client who is complaining of thick respiratory secretions that are difficult to clear. What should the nurse encourage the client to do to help clear those secretions?

A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

A nurse is assessing a client’s cranial nerves. What cranial nerve would be assessed when checking a client’s gag reflex?

A nurse is giving preoperative instructions to a patient scheduled for surgery. The patient tells the nurse, “I will prepare my advance directives before I come to the hospital.” Which statement shows the client understands advance directives?