A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?

2 hr

8 hr

6 hr

4 hr

Answer and Explanation

The Correct Answer is D

A. 2 hr: While some patients may tolerate faster infusion rates, the maximum safe time is 4 hours, and there is no requirement to complete it in 2 hours.

B. 8 hr: Blood cannot be left out for 8 hours due to the increased risk of bacterial growth and contamination.

C. 6 hr: Infusing blood over 6 hours exceeds the safe time limit and poses a risk of bacterial contamination.

D. 4 hr: To reduce the risk of bacterial contamination, a unit of packed RBCs must be transfused within 4 hours of starting the infusion. This time frame ensures that the blood remains safe for the patient while minimizing exposure to room temperature.

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Correct Answer is D

Explanation

A. Explain the procedure to the patient’s family: While helpful, this is not as crucial as ensuring patient comfort and pain management during the procedure itself.

B. Observe the patient for bleeding: Observing for bleeding is important post-procedure rather than beforehand.

C. Drape the biopsy site: Draping is part of the procedure setup, but pain management is more critical for patient preparation.

D. Administer an analgesic to the patient: Administering an analgesic is essential to manage pain and discomfort during a bone marrow biopsy. This ensures the patient is as comfortable as possible.

A. Initiate a 2 L/day fluid restriction. B. Assist with administering a blood transfusion. C. Withhold opioids to avoid dependence. D. Encourage exercise.

Correct Answer is B

Explanation

A. Initiate a 2 L/day fluid restriction: Hydration is crucial in sickle cell crisis to prevent further sickling and reduce blood viscosity. A fluid restriction would worsen the crisis.

B. Assist with administering a blood transfusion: Blood transfusions are commonly given during sickle cell crisis to manage anemia and reduce the concentration of sickled cells, which can improve oxygen delivery and relieve pain.

C. Withhold opioids to avoid dependence: Pain management, including opioids if needed, is essential during a sickle cell crisis. The risk of dependence is secondary to controlling acute pain.

D. Encourage exercise: Rest is recommended during a crisis to reduce oxygen demand and prevent further sickling. Exercise would increase oxygen needs, worsening the crisis.

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A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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