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 C
Explanation
A) Decreased thirst: Clients with heart failure often experience fluid retention, which can lead to increased thirst rather than decreased thirst. The body may signal the need for more fluids due to the imbalance caused by fluid retention.
B) Thready pulse: A thready pulse is not a common manifestation of heart failure. Heart failure typically presents with other symptoms such as fluid retention, shortness of breath, and fatigue.
C) Weight gain: Weight gain is a common manifestation of heart failure due to fluid retention. The accumulation of excess fluid in the body can lead to noticeable weight gain, which is an important indicator for monitoring the client’s condition.
D) Tachycardia: Tachycardia, or an increased heart rate, can occur in clients with heart failure as the heart tries to compensate for its reduced pumping efficiency. However, weight gain due to fluid retention is a more direct and common manifestation of heart failure.
Correct Answer is D
Explanation
A. Premature Infant Pain Profile (PIPP): This scale is specifically designed for assessing pain in preterm infants and may not be suitable for a newborn delivered at 38 weeks of gestation.
B. FACES pain rating scale: This scale is typically used for older children who can understand and relate to facial expressions, making it inappropriate for assessing pain in newborns.
C. Visual analog scale (VAS): This scale is also not suitable for newborns, as it requires the ability to understand and interpret a continuous scale, which newborns cannot do.
D. Neonatal Infant Pain Scale (NIPS): This is the most appropriate choice for assessing pain in a newborn. It evaluates indicators such as facial expression, cry, breathing patterns, and extremity movement, making it suitable for this age group and context.
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