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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Impaired skin integrity - While the patient does have skin issues due to ulcerations, the root cause is impaired perfusion. Addressing the impaired tissue perfusion will help improve skin integrity.

B. Alteration in activity tolerance - Although the patient might experience reduced activity tolerance due to the heaviness and discomfort, it is not as critical as ensuring adequate tissue perfusion.

C. Impaired tissue perfusion - This diagnosis is the priority because varicose veins and ulcerations with lower extremity edema suggest that there is poor blood flow to the tissues, which can lead to further complications such as worsening ulcerations and potential infection. Effective tissue perfusion is critical to healing and preventing further deterioration.

D. Alteration in body image - This is a valid concern for the patient but is not as immediate or life-threatening as impaired tissue perfusion and the potential for complications from poor circulation.

A. Avoid crowds B. Eat plenty of fresh fruits and vegetables C. Take temperature weekly. D. Perform mild exercise, such as gardening

Correct Answer is A

Explanation

A. Avoid crowds - Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens.

B. Eat plenty of fresh fruits and vegetables - While generally healthy, fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Cooked or properly washed and peeled produce is safer.

C. Take temperature weekly - Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early.

D. Perform mild exercise, such as gardening - Gardening can expose individuals to soil-borne organisms that could lead to infections. Indoor exercises or those that don’t involve potential pathogen exposure are safer.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

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