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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A: Alternative communication methods are more applicable to clients with severe speech or cognitive impairments, which are not universally present in multiple sclerosis.
B: Using clock numbers to describe food placement is typically recommended for visually impaired clients, not specifically for those with multiple sclerosis.
C: Touching the client's arm before speaking is a technique used for clients with hearing impairments.
D: Multiple sclerosis can cause fine motor skill impairment and muscle weakness. Providing large-handled utensils can help maintain independence in eating by making it easier to grip and use utensils.

Correct Answer is []

Explanation

Potential condition:

The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.

The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.

Action to take:

In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.

Parameters to monitor:

To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.

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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 contributing to the plan of care for a client who has multiple sclerosis. The nurse should recommend including which of the following interventions in the plan of care to assist the client in overcoming barriers related to this condition?

Correct Answer is D

Explanation

Correct Answer is []

Explanation

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