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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: This action is not appropriate, as sterile items should be placed at least 2.5 cm (1 in) away from the edge of the sterile field to maintain sterility and prevent contamination.

B. Open the outermost flap of the sterile kit toward the body: The correct practice is to open the outermost flap away from the body. This technique helps prevent any contaminants from the nurse's clothing or body from falling into the sterile field.

C. Place the cap from the solution sterile side up on a clean surface: This is the correct action. By placing the cap sterile side up, the nurse minimizes the risk of contamination to the sterile solution and maintains the integrity of the sterile field.

D. Set up the sterile field 5 cm (2 in) below waist level: Setting up a sterile field below waist level increases the risk of contamination, as it may come into contact with non-sterile surfaces. The sterile field should be set up at waist level or higher to maintain sterility.

A. Touch the client gently to announce presence. B. Ensure there is high-wattage lighting in the client's room. C. Keep objects in the client's room in the same place. D. Approach the client from the side. E. Allow extra time for the client to perform tasks.

Correct Answer is ["A","C","E"]

Explanation

A. Touch the client gently to announce presence: Gently touching the client’s arm or shoulder can help orient them to your presence and is a considerate way to communicate, especially when they have vision loss.

B. Ensure there is high-wattage lighting in the client's room: While good lighting is important, high-wattage lighting can create glare, which may be uncomfortable or disorienting for clients with vision loss. Instead, softer, diffused lighting is often more effective.

C. Keep objects in the client's room in the same place: Maintaining a consistent layout in the client’s environment helps them navigate safely and independently. It minimizes confusion and reduces the risk of accidents.

D. Approach the client from the side: Approaching from the front is typically better for clients with vision loss, as it allows them to see you (if they have some vision) and helps them feel less startled.

E. Allow extra time for the client to perform tasks: Providing extra time respects the client's pace and fosters independence. It acknowledges the challenges they may face due to vision loss, allowing them to complete tasks without feeling rushed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Correct Answer is C

Explanation

A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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