A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
1 hour
2 hours
3 hours
4 hours
The Correct Answer is D
Choice A reason: Infusing packed RBCs over 1 hour is typically too rapid for most patients and can increase the risk of adverse reactions, especially in those with cardiovascular compromise.
Choice B reason: A 2hour infusion may be appropriate in certain emergency situations where rapid correction of anemia is required, but it is not the standard practice for routine transfusions.
Choice C reason: A 3hour infusion is less commonly used and does not provide any specific advantage over the standard 4hour infusion time.
Choice D reason: The standard practice is to complete the transfusion of packed RBCs within 4 hours. This duration minimizes the risk of bacterial growth and transfusion reactions, as recommended by the American Society of Hematology and other clinical guidelines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Offering the bedpan every 2 hours is not specifically related to preventing urinary tract infections (UTIs) and may not be necessary unless the client has other needs that require frequent toileting.
Choice B reason: Cleansing the perineum from front to back is a standard practice to prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTIs.
Choice C reason: Encouraging fluid intake is crucial for clients with a spinal cord injury because it helps to flush out the urinary tract, preventing the buildup of bacteria that can cause UTIs.
Choice D reason: An indwelling urinary catheter may be necessary for a client with a T4 spinal cord injury who cannot effectively empty the bladder, but it should be used with caution as it can also increase the risk of UTIs. The decision to use an indwelling catheter should be based on a thorough assessment and consideration of all other options.
Correct Answer is B
Explanation
Choice A reason: The visibility of chest tube eyelets is not typically a concern unless there is evidence that the tube is dislodged. In normal circumstances, the eyelets may not be visible, and this does not necessarily indicate a need for intervention.
Choice B reason: The development of subcutaneous emphysema, which is the presence of air in the subcutaneous tissue, can be a sign of a serious complication such as a pneumothorax. It requires immediate assessment and possible intervention to prevent further complications.
Choice C reason: Tidal fluctuation in the water seal chamber is a normal finding when a chest tube is in place. It indicates that the system is patent and functioning correctly as it reflects the pressure changes in the pleural space during respiration.
Choice D reason: Continuous bubbling in the suction control chamber may indicate an air leak in the system, which could be normal if the system is set to continuous suction. However, if the bubbling is vigorous and the system is not set to continuous suction, it may indicate a new air leak and require intervention.
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