A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

Obtain filterless IV tubing.

Place the blood in a warmer for 1 hr.

Use a 24-gauge IV catheter.

Prime IV tubing with 0.9% sodium chloride.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Obtain filterless IV tubing: Blood transfusions require specialized IV tubing with an in-line filter to remove clots and debris. Using filterless tubing would increase the risk of transfusing particulate matter into the client’s bloodstream.

B. Place the blood in a warmer for 1 hr: Blood should only be warmed if specifically prescribed and done using an approved device immediately before administration. Prolonged warming increases the risk of bacterial growth and hemolysis.

C. Use a 24-gauge IV catheter: Packed RBCs should be administered through a larger-bore catheter (typically 18–20 gauge) to allow adequate flow and prevent hemolysis. A 24-gauge catheter is too small for efficient transfusion.

D. Prime IV tubing with 0.9% sodium chloride: Normal saline is the only compatible solution for priming and administering blood products. It prevents clotting and hemolysis while ensuring that the blood flows freely without interacting with other IV solutions.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Urinary output 20 mL/hr: A urinary output less than 30 mL/hr in an adult indicates potential renal hypoperfusion or urinary retention. This is a priority finding that should be reported to the provider promptly.

B. Serous drainage on abdominal dressing: Serous drainage is a normal postoperative finding, indicating normal wound healing and fluid exudate. It does not require immediate provider notification.

C. Temperature 37.6° C (99.7° F): This temperature is slightly elevated but within the expected postoperative range due to the inflammatory response. It does not indicate an urgent complication.

D. Blood pressure 100/70 mm Hg: This blood pressure is within normal limits for many adults and is not necessarily concerning in a postoperative context unless accompanied by other symptoms such as tachycardia or dizziness.

A. Physical therapy B. Speech therapy C. Respiratory therapy D. Occupational therapy

Correct Answer is B

Explanation

A. Physical therapy: Physical therapists focus on improving mobility, balance, and strength. While important after a stroke, they do not primarily address swallowing difficulties.

B. Speech therapy: Speech-language pathologists assess and treat dysphagia (swallowing disorders) and communication difficulties. Referral to speech therapy ensures the client receives appropriate evaluation and interventions to prevent aspiration and maintain nutrition.

C. Respiratory therapy: Respiratory therapists manage airway and pulmonary function issues. They may assist if complications like aspiration pneumonia occur, but they do not directly treat swallowing difficulties.

D. Occupational therapy: Occupational therapists help with activities of daily living and adaptive strategies for self-care. While they may assist with feeding techniques or positioning, they do not specialize in swallowing assessments or interventions.

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A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

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