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

Answer and Explanation

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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Correct Answer is A

Explanation

A) Mashed potatoes:

Mashed potatoes are an appropriate choice for a soft diet as they are easy to chew and swallow. A soft diet typically includes foods that are tender, moist, and easy to digest, which helps in minimizing difficulty while eating.

B) High-fiber cereals:

High-fiber cereals are not suitable for a soft diet. They can be hard and difficult to chew, and the high fiber content might irritate the digestive tract, making them less ideal for individuals on a soft diet.

C) Fruit with the skin:

Fruits with the skin can be difficult to chew and digest, especially for those on a soft diet. The skin of fruits can be tough and may not be appropriate for someone needing a diet with soft, easily manageable foods.

D) Raw vegetables:

Raw vegetables are typically hard and require thorough chewing, which makes them unsuitable for a soft diet. Soft diets require foods that are tender and easy to chew, so raw vegetables do not meet these criteria.

A. Extreme thirst B. Paresthesias C. Lethargy D. Blood clots

Correct Answer is C

Explanation

A) Extreme thirst: While extreme thirst can be associated with electrolyte imbalances, particularly in conditions of dehydration or hypernatremia (elevated sodium levels), a sodium level of 116 mEq/L indicates hyponatremia (low sodium levels). Extreme thirst is less typical for hyponatremia.

B) Paresthesias: Paresthesias, or abnormal sensations like tingling or numbness, are more commonly associated with conditions of low calcium or potassium levels rather than sodium. In hyponatremia, neurological symptoms can occur, but they typically include lethargy or confusion rather than specific paresthesias.

C) Lethargy: Lethargy is a common symptom of severe hyponatremia. Low sodium levels can lead to cerebral edema and neurological disturbances, resulting in symptoms such as lethargy, confusion, and even seizures. This is a direct consequence of the altered osmotic balance affecting brain function.

D) Blood clots: Hyponatremia is not typically associated with an increased risk of blood clots. Blood clots are more related to conditions affecting coagulation factors, which are not directly influenced by sodium levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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