A nurse is planning care for a client who is scheduled to receive a transfusion of packed RBCs.
Which of the following actions should the nurse plan to take?
Store the unit of blood at room temperature for 1 hr prior to the infusion.
Ensure that the transfusion is completed within 6 hr.
Obtain venous access using a 22-gauge needle.
Use a solution of 0.9% sodium chloride to flush the transfusion tubing.
The Correct Answer is D
The correct answer is D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.
Choice A reason: Storing a unit of blood at room temperature for 1 hour prior to the infusion is not recommended. Blood products should be kept refrigerated until just before the transfusion to minimize the risk of bacterial contamination. The recommended storage temperature for packed RBCs is 1-6°C. If blood is left at room temperature, it should be infused within 30 minutes to ensure safety.
Choice B reason: Ensuring that the transfusion is completed within 6 hours is not correct. The standard practice is to complete a blood transfusion over 2 to 4 hours, depending on the volume and the patient’s condition. This is to reduce the risk of bacterial growth and transfusion reactions. Prolonging the transfusion time beyond 4 hours increases the risk of bacterial contamination and can compromise the efficacy of the transfused red blood cells.
Choice C reason: Obtaining venous access using a 22-gauge needle is not ideal for a transfusion of packed RBCs. A larger bore needle, typically an 18-gauge or 20-gauge, is preferred to ensure adequate flow of the viscous packed RBCs and to prevent hemolysis. The smaller the gauge number, the larger the needle diameter, so a 22-gauge needle might be too small and could damage the red blood cells during the transfusion.
Choice D reason: Using a solution of 0.9% sodium chloride to flush the transfusion tubing is the correct action. Normal saline is isotonic and is the only fluid compatible with packed RBCs. It is used to prime the transfusion set and to flush the line before and after the transfusion to prevent hemolysis and clotting within the tubing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale:
The client has influenza, which is a respiratory illness that can be transmitted through droplets when the infected person coughs, sneezes, or talks. The UAP is in close contact with the client while assisting them to sit up in bed to eat lunch. Therefore, it is necessary for the UAP to wear a face mask in addition to a gown and gloves to prevent the spread of the virus.This is in line with the Centers for Disease Control and Prevention (CDC) guidelines, which recommend that healthcare personnel wear a face mask when they are in the same room as a patient with suspected or confirmed influenza.
Choice B rationale:
A fitted respirator mask is not necessary in this situation.According to the Occupational Safety and Health Administration (OSHA), respirators are required for airborne diseases such as tuberculosis, but not for influenza, which is a droplet-transmitted disease. Therefore, reminding the UAP to apply a fitted respirator mask before entering the client’s room is not the most appropriate action.
Choice C rationale:
Assigning the UAP to provide care for another client and assuming full care of the client is not the most appropriate action in this situation. The UAP is already wearing a gown and gloves, which are part of the standard precautions for any patient care.The UAP just needs to add a face mask to their personal protective equipment (PPE) to safely assist the client.
Choice D rationale:
Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is always a good practice. However, it does not address the immediate need for the UAP to wear a face mask while in close contact with the client. Therefore, it is not the most appropriate action in this situation.
Correct Answer is D
Explanation
Choice A rationale:
Give the client protamine if signs of magnesium sulfate toxicity occur. Protamine is not the antidote for magnesium sulfate toxicity. Calcium gluconate or calcium chloride is used to counteract the effects of magnesium sulfate toxicity by antagonizing the action of magnesium on the neuromuscular junction and the heart.
Choice B rationale:
Monitor the FHR via Doppler every 30 min. While fetal heart rate (FHR) monitoring is important during magnesium sulfate infusion due to the risk of fetal distress, using Doppler every 30 minutes may not provide continuous and accurate monitoring. Continuous electronic fetal monitoring is the standard of care in this situation.
Choice C rationale:
Restrict the client's total fluid intake to 250 mL/hr. Magnesium sulfate is excreted by the kidneys, so maintaining adequate urine output is crucial to prevent magnesium toxicity. Restricting fluid intake to 250 mL/hr would likely reduce urine output, leading to an increased risk of magnesium sulfate accumulation in the body, which could be harmful.
Choice D rationale:
Measure the client's urine output every hour. Monitoring urine output is essential during magnesium sulfate infusion as it helps assess renal function and magnesium excretion. Adequate urine output (at least 30 mL/hr) is necessary to prevent magnesium toxicity. Therefore, measuring the client's urine output every hour is a critical nursing intervention to ensure the safety of the client.
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