A nurse is caring for a client with an order for one unit of packed red blood cells (PRBCs). The nurse should anticipate to remain ate client's bedside during which time period of the infusion?
The first 2 min
The final 15 min
The first 15 min
The final 2 min
The Correct Answer is C
A) The first 2 min: While it is essential to monitor the client closely during the first few minutes of a PRBC infusion, a two-minute observation period is insufficient to detect most acute transfusion reactions. Many reactions, such as fever, chills, and allergic responses, can take longer to manifest.
B) The final 15 min: Monitoring during the final 15 minutes is important to ensure the infusion is completed without complications. However, the most critical time for monitoring is at the beginning of the infusion, as acute reactions are more likely to occur early on.
C) The first 15 min: The first 15 minutes of a PRBC transfusion are crucial because most acute transfusion reactions, such as allergic reactions, febrile non-hemolytic reactions, and hemolytic reactions, occur within this time frame. The nurse should remain at the bedside to promptly identify and manage any adverse reactions, ensuring the client's safety.
D) The final 2 min: Monitoring during the final two minutes of the infusion is also important, but it is not the critical time frame for detecting most transfusion reactions. Observing the client closely during the initial phase of the transfusion is essential to address any immediate complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) The client is reporting constipation:
Constipation is a common issue with enteral feeding, often due to decreased fluid intake or lack of fiber. While it is important to manage constipation to improve comfort and bowel function, it is not as urgent as dealing with vomiting.
B) The client reports being thirsty:
Thirst can be a sign of dehydration or inadequate fluid intake. Although it should be addressed to ensure proper hydration, it is less critical compared to vomiting, which poses immediate risks.
C) The client is vomiting the enteral formula:
Vomiting is a priority concern because it can lead to aspiration, dehydration, electrolyte imbalances, and further complications. Addressing the cause of vomiting and managing it promptly is crucial for the client’s safety.
D) The client is experiencing abdominal cramping:
Abdominal cramping can be related to the feeding rate, type of formula, or intolerance. While it requires attention, it is less urgent than addressing vomiting, which could have more immediate and serious consequences.
Correct Answer is D
Explanation
A. 8 hr - Infusing one unit of packed red blood cells (PRBCs) over 8 hours is too long. Typically, PRBCs are infused over a shorter period to avoid complications.
B. 4 hr - Infusing PRBCs over 4 hours is still within acceptable limits, but the standard time for PRBC transfusion is usually shorter.
C. 6 hr - Infusing PRBCs over 6 hours is longer than usual. The recommended duration for infusing one unit of PRBCs is generally shorter.
D. 2 hr - The standard time to infuse one unit of PRBCs is typically between 1.5 to 2 hours. This duration helps ensure the effective delivery of red blood cells while minimizing the risk of transfusion reactions.
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