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 C

Explanation

Choice A Reason:

The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.

Choice B Reason:

The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.

Choice C Reason:

The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.

Choice D Reason:

The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.

A. Open the client’s visual acuity using a Snellen chart. B. Whisper none of the client’s ears while blocking the other. C. Ask the client to inspect up. D. Ask the client to smile.

Correct Answer is C

Explanation

Choice A Reason:

Open the client’s visual acuity using a Snellen chart is incorrect. This action assesses cranial nerve II (optic nerve), which is responsible for vision. The Snellen chart is used to measure visual acuity, not the function of cranial nerve VI

Choice B Reason:

Whisper none of the client’s ears while blocking the other is incorrect. This action assesses cranial nerve VIII (vestibulocochlear nerve), which is responsible for hearing and balance. Whispering tests the auditory function of this nerve.

Choice C Reason:

Ask the client to inspect up is correct. Cranial nerve VI (abducens nerve) controls the lateral rectus muscle, which is responsible for moving the eye outward. Asking the client to look up and outward helps assess the function of this nerve.

Choice D Reason:

Ask the client to smile is incorrect. This action assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Smiling tests the motor function of this nerve.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

Correct Answer is C

Explanation

A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. How should the nurse explain to the client how this method of oxygen delivery performs?

A nurse is preparing to administer furosemide 4 mg via IV bolus to a client. The amount available is furosemide 10 mg/mL. How many mL should the nurse administer per dose (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A client has an order for continuous bladder irrigation. What should the nurse do with the irrigation solution on the intake and output (I&O) sheet when calculating the fluid balance for this client?

A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?

A client has an injury to the left ankle requiring partial weight bearing. The client is elderly with a history of balance deficit. Which assistive device would be most appropriate for this client?

A nurse accidentally sticks her hand with a needle after administering an intramuscular (IM) injection to a client. Which action should the nurse take first?

A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?