A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
The first 2 min
The final 2 min
The final 15 min
The first 15 min
The Correct Answer is D
A. The first 2 min - This is too short a period to monitor effectively for transfusion reactions.
B. The final 2 min - Transfusion reactions are more likely to occur at the beginning of the transfusion rather than at the end.
C. The final 15 min - While it’s still important to monitor, reactions are most likely to be detected earlier in the infusion.
D. The first 15 min - Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for any signs of a reaction, such as fever, chills, rash, or difficulty breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "To place my leg under a heat lamp every 3 hours." Using a heat lamp can cause burns and uneven heating, which is not recommended for cellulitis.
B. "I will keep a heating pad on the calf of my right leg when I am lying down." Continuous heat application can cause burns and damage tissues, especially in clients with impaired sensation or circulation.
C. "I will wrap a warm, wet towel around my right calf every 4 hours." Using a warm, wet towel ensures that heat is evenly distributed and provides moist heat, which can help increase blood flow and promote healing in cellulitis.
D. "I will sit on the side of the tub and soak my right leg two times every day." Soaking the leg may not maintain consistent warmth and could also introduce the risk of infection if the water is not clean.
Correct Answer is D
Explanation
A. "You have had a gastrointestinal bleed.": While a GI bleed can cause anemia and fatigue, it is not a direct cause of fatigue in sickle cell anemia.
B. "You have a low ferritin level.": Low ferritin indicates iron deficiency anemia, not directly related to sickle cell anemia.
C. "You have an autoimmune disease.": Sickle cell anemia is a genetic disorder, not an autoimmune disease.
D. "You have fewer red blood cells." Sickle cell anemia results in a decreased number of healthy red blood cells (RBCs) because the sickled cells are fragile and prone to breaking apart. This leads to anemia, which reduces the blood's ability to carry oxygen, causing fatigue and tiredness.
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