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 D
Explanation
A. Slurred speech - This is not a common symptom of iron deficiency anemia. It might suggest a neurological issue or other condition.
B. Confusion - While severe anemia might lead to confusion due to reduced oxygen delivery to the brain, it is not as common as fatigue and is usually seen in more advanced stages or in combination with other factors.
C. Pain - Pain is not a typical symptom of iron deficiency anemia unless it is related to other conditions like muscle fatigue from overall weakness.
D. Fatigue - Fatigue is a hallmark symptom of iron deficiency anemia due to the decreased ability of the blood to carry oxygen to tissues, leading to overall tiredness and lack of energy.
Correct Answer is A
Explanation
A. 1 cup canned black beans - Black beans are high in iron and an excellent dietary recommendation for someone with iron deficiency anemia.
B. 8 oz whole milk - While nutritious, milk is not a significant source of iron and can actually inhibit iron absorption due to its calcium content.
C. 1.5 oz raisins - Raisins do contain some iron, but the amount is relatively small compared to black beans. They are a good supplement but not the best primary source of iron.
D. 8 oz black tea - Tea contains tannins that can inhibit iron absorption, making it an unsuitable recommendation for someone needing to increase their iron levels.
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