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 ["A","C","E"]

Explanation

A. Increased heart rate - Tachycardia can occur as the heart compensates for increased blood volume and the need to maintain effective circulation.

B. Increased hematocrit - Hematocrit usually decreases in fluid overload because the increased plasma volume dilutes the red blood cells.

C. Increased blood pressure - Excess fluid volume often leads to hypertension as there is more fluid for the heart to pump, increasing vascular resistance.

D. Increased temperature - Temperature is not directly affected by fluid overload; fever or changes in temperature are more likely related to infection or other inflammatory responses.

E. Increased respiratory rate - Fluid overload can cause pulmonary congestion and decreased oxygenation, leading to increased respiratory effort to maintain adequate oxygen levels.

A. Scatter rugs are present in the kitchen, B. Handrails are present in the bathroom. C. Electrical cords are placed along the walls. D. Uses a microwave for cooking.

Correct Answer is A

Explanation

A. Scatter rugs are present in the kitchen - Scatter rugs can cause tripping and slipping, posing a significant fall risk for someone with vision impairment.

B. Handrails are present in the bathroom - Handrails provide support and help prevent falls, making them a safety feature, not a risk.

C. Electrical cords are placed along the walls - This helps prevent tripping over cords, thus reducing fall risk.

D. Uses a microwave for cooking - A microwave is generally safer than a stove as it reduces the risk of burns and fires, making it a safety feature.

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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

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Explanation

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Correct Answer is A

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