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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: An oral temperature of 38.2°C (100.76°F) is slightly elevated but can be expected postoperatively as the body responds to surgical stress. It is not necessarily an indication of a complication unless it rises significantly or is accompanied by other symptoms.

Choice B reason: The output of burgundy colored urine can indicate bleeding in the urinary tract, which is a potential complication after TURP. Normal urine color ranges from pale yellow to deep amber, depending on hydration levels. Burgundy colored urine postTURP could suggest the presence of blood, warranting further assessment and intervention.

Choice C reason: Feeling an urge to void despite having an indwelling urinary catheter can be uncomfortable but is not uncommon after TURP due to irritation of the bladder. It is not typically a sign of a complication unless accompanied by other symptoms such as pain or difficulty urinating once the catheter is removed.

Choice D reason: A pulse rate of 58/min is within the normal resting range for adults, which is typically 60100 beats per minute. A lower than average pulse rate postoperatively might be normal for the patient, especially if they are on medications like betablockers, or it could be a sign of a good fitness level.

A. Offer the client the bedpan every 2 hours. B. Cleanse the perineum from front to back. C. Encourage fluid intake at and between meals. D. Obtain a prescription for an indwelling urinary catheter.

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.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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