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?
Administer the blood via a 21-gauge IV needle.
Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion.
Check the client's vital signs from the previous shift prior to the initiation of the transfusion.
Set the IV infusion pump to administer the blood over 6 hr.
The Correct Answer is B
A. A larger-bore needle (usually 18- to 20-gauge) is recommended for blood transfusions to prevent hemolysis and ensure adequate flow rate.
B. Flushing the tubing with 0.9% sodium chloride ensures that it is primed and free from air or any incompatible solutions before starting the blood transfusion.
C. Vital signs should be checked immediately before, during, and after the transfusion to monitor for adverse reactions.
D. Blood transfusions are typically completed over 2 to 4 hours, depending on the clinical context, to reduce the risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Changing a dressing on an implanted central venous access device involves a sterile procedure and assessment, requiring the skills and knowledge of a licensed nurse.
B. Removing an NG tube is a task beyond an AP’s scope and requires the specialized skills of a registered nurse.
C. Suctioning a tracheostomy requires specialised training and skill to perform safely and should not be delegated to assistive personnel.
D. Performing postmortem is within the scope of an assistive personnel. It does not require any specialized skills and knowledge of a registered nurse.
Correct Answer is C
Explanation
A: Percussion should be performed with a cupped hand to provide effective airway clearance, not with a flat hand.
B: Postural drainage is typically performed multiple times per day to help clear secretions from the lungs in cystic fibrosis.
C: Postural drainage is often performed before meals to minimize the risk of vomiting due to manipulation of the abdomen.
D: Bronchodilators are not typically administered after postural drainage; they are used to help open the airways before the procedure.
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