A nurse is planning care for a child who has a prescription to transfuse 2 units of packed RBCs.
Which of the following interventions should the nurse include in the plan of care?
Infuse the packed RBC within 4 hours
Infuse dextrose 5% in water during the infusion of packed RBCs.
Store the second unit of blood at room temperature for up to 2 hr.
Administer RBCs using non-filtered IV tubing.
The Correct Answer is A
A. Packed red blood cells should typically be infused within 4 hours to reduce the risk of bacterial contamination and ensure potency.
B. Dextrose 5% in water is not typically infused with packed RBCs; the focus is on administering blood products as prescribed.
C. Blood products are typically stored under controlled conditions and transfused promptly after verification and compatibility checks.
D. Filtered IV tubing is often used for blood transfusions to minimize the risk of air embolism and particle infusion, but it's not the primary intervention listed for the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Tachypnea is a sign of respiratory distress and may indicate hypoxia, dehydration, or increased work of breathing. The nurse should report this finding to the provider and monitor the infant's oxygen saturation, heart rate, and respiratory rate.
B) Coughing is a common symptom of RSV and may not require immediate reporting unless severe.
C) Rhinorrhea (runny nose) is a common symptom of RSV and may not require immediate reporting unless severe.
D) Pharyngitis (sore throat) is a common symptom of RSV but is not as urgent as tachypnea.
Correct Answer is ["B","C","D"]
Explanation
A. Salicylic acid is contraindicated for children under 12 years old because it can cause Reye's syndrome, a rare but serious condition that affects the brain and liver.
B. Sulfamethoxazole and trimethoprim is an antibiotic that is commonly used to treat UTIs caused by bacteria such as E. coli. It is anticipated for this client because it can help clear the infection and reduce the symptoms.
C. Proper perineal hygiene is important for preventing UTIs, especially in girls who have a shorter urethra than boys. The nurse should educate the child about wiping from front to back after using the toilet, avoiding bubble baths and scented products, and changing underwear daily.
D. Sunscreen is advised for clients taking sulfamethoxazole and trimethoprim because this medication can increase the sensitivity of the skin to sunlight and cause sunburns or rashes.
E. Fluid restriction is contraindicated for clients with UTIs because it can increase the concentration of bacteria in the urine and worsen the infection. The nurse should ensure that the child drinks plenty of fluids, such as water, juice, or milk, to flush out the bacteria and dilute the urine.
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