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 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.

A. DSW B. 0.3% NS C. Lactated Ringers D. 0.9% NS

Correct Answer is D

Explanation

A) D5W: Dextrose 5% in water (D5W) is not used with blood transfusions because it can cause hemolysis of the red blood cells due to its hypotonic nature. It can also potentially cause clumping and clotting.

B) 0.3% NS: This is a hypotonic saline solution, which can lead to hemolysis of red blood cells when used as a diluent for blood products. It is not appropriate for use in blood transfusions.

C) Lactated Ringers: Although lactated Ringer's solution is often used for fluid resuscitation, it contains calcium, which can cause clotting in the blood product. Therefore, it is not suitable for use with blood transfusions.

D) 0.9% NS: Normal saline (0.9% sodium chloride) is isotonic and the only solution recommended for use with blood transfusions. It does not cause hemolysis of red blood cells, does not alter the composition of the blood product, and helps to maintain the patency of the IV line. It is the standard diluent used in blood transfusions to ensure the safe administration of blood products.

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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?

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Naxlex Comprehensive Predictor Exams

﻿A nurse is assessing a client with a sodium level of 116 mEq/L (135-145 mEq/L). Which finding should the nurse expect for this client to have?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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