A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
Check the client's vital signs from the previous shift prior to the initiation of the transfusion.
Administer the blood via a 21-gauge IV needle.
Set the IV infusion pump to administer the blood over 6 hr.
Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion.
The Correct Answer is D
A) Check the client’s vital signs from the previous shift prior to the initiation of the transfusion: Checking the client’s vital signs from the previous shift is not sufficient. The nurse should obtain a set of baseline vital signs immediately before starting the transfusion to monitor for any changes or reactions during the procedure.
B) Administer the blood via a 21-gauge IV needle: A 21-gauge IV needle is too small for administering packed RBCs. A larger gauge needle, such as an 18- or 20-gauge, is recommended to ensure the blood flows smoothly and to reduce the risk of hemolysis.
C) Set the IV infusion pump to administer the blood over 6 hr: Administering the blood over 6 hours is not appropriate. Packed RBCs should be transfused within 4 hours to reduce the risk of bacterial contamination and ensure the blood remains viable.
D) Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion: Flushing the blood administration tubing with 0.9% sodium chloride is the correct action. This helps to clear the line of any residual substances and ensures that the blood product is delivered effectively and safely to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Increased calcium levels are typically not expected in clients with chronic kidney disease (CKD). In fact, CKD often leads to decreased calcium levels due to impaired renal function, which affects vitamin D metabolism and calcium absorption.
B) Increased bicarbonate levels would suggest a metabolic alkalosis, which is not common in CKD. Clients with CKD often experience metabolic acidosis due to the kidneys' inability to excrete hydrogen ions effectively, leading to decreased bicarbonate levels.
C) Increased hemoglobin levels are not expected in CKD; rather, clients often experience anemia due to decreased erythropoietin production by the kidneys. Therefore, hemoglobin levels are typically low in individuals with chronic kidney disease.
D) Increased creatinine is a hallmark finding in chronic kidney disease. It indicates a decline in kidney function, as creatinine is a waste product that is normally excreted by the kidneys. Elevated creatinine levels reflect the kidneys' reduced ability to filter and excrete waste, which is characteristic of CKD.
Correct Answer is A
Explanation
A) Assault:Assault refers to an intentional act that creates a reasonable apprehension of imminent harmful or offensive contact. In this scenario, the newly licensed nurse’s statement about inserting a urinary catheter if the client does not void can be perceived as a threat, causing the client to fear an unwanted procedure.
B) Libel:Libel involves making false, defamatory statements in written form that harm someone’s reputation. This option is not applicable in this context, as the nurse’s statement was verbal and did not involve written defamation.
C) Negligence:Negligence occurs when a healthcare provider fails to meet the standard of care, resulting in harm to the client. While the nurse’s statement may be inappropriate, it does not constitute negligence, as it does not involve a breach of the standard of care leading to harm.
D) Battery:Battery involves intentional physical contact with another person without their consent. In this case, the nurse has not yet performed any physical act, so battery has not occurred. The threat alone constitutes assault, not battery.
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