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 A

Explanation

A. Faint pedal pulse of left leg: A faint pedal pulse indicates poor circulation and is a clear sign of altered tissue perfusion. It suggests that the blood flow to the affected extremity may be compromised, warranting immediate assessment and intervention.

B. Pain with movement of the left great toe: While pain may indicate an issue, it does not specifically indicate altered tissue perfusion. Pain can result from various causes, including injury or inflammation, but it is not a direct measure of blood flow.

C. Purulent drainage at the pin site: Purulent drainage suggests infection rather than altered perfusion. While infections can affect tissue health, this finding does not directly indicate compromised blood flow to the extremity.

D. Warm skin temperature distal to pin site: Warm skin typically suggests adequate perfusion, as warmth can indicate good blood flow. In contrast, coolness or coldness would be a more concerning sign of altered perfusion.

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. B. Open the outermost flap of the sterile kit toward the body. C. Place the cap from the solution sterile side up on a clean surface. D. Set up the sterile field 5 cm (2 in) below waist level.

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.

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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

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