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) Flushing: Flushing can occur as the body tries to regulate temperature, but it is not typically an adverse reaction to cooling measures.

B) Restlessness: While restlessness can indicate discomfort, it is not a specific sign of an adverse reaction to cooling therapy.

C) Shivering: This is the correct answer. Shivering is a direct response to cold exposure and indicates that the body is trying to generate heat in response to the cooling blanket. It can be an adverse reaction as it can increase metabolic demand and may counteract the intended effects of the cooling.

D) Tachycardia: Although an increase in heart rate can occur with fever or anxiety, it is not a definitive indicator of an adverse reaction to cooling. It can also be a normal physiological response.

A. "I should expect the provider to evaluate the client within 4 hours of restraint application." B. "I should visually monitor the clit continuously when in mechanical restraints." C. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." D. "I should ask the provider to write a prescription for mechanical restraints as needed."

Correct Answer is B

Explanation

A) “I should expect the provider to evaluate the client within 4 hours of restraint application.”:The provider must evaluate the client within a shorter timeframe, typically within 1 hour of applying mechanical restraints, to ensure the client’s safety and appropriateness of the intervention.

B) “I should visually monitor the client continuously when in mechanical restraints.”:Continuous visual monitoring is essential to ensure the client’s safety and well-being while in mechanical restraints. This allows for immediate intervention if any complications or distress arise.

C) “I should assess the client’s skin integrity every 8 hours while in mechanical restraints.”:Skin integrity should be assessed more frequently, typically every 2 hours, to prevent skin breakdown and other complications associated with prolonged use of restraints.

D) “I should ask the provider to write a prescription for mechanical restraints as needed.”:Mechanical restraints should not be used on an as-needed basis. They require a specific, time-limited order from a provider, and their use must be justified and documented according to strict guidelines and protocols.

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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

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Explanation

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Correct Answer is B

Explanation

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