A nurse is planning care for a patient who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
8 hr
6 hr
4 hr
2 hr
The Correct Answer is C
A. 8 hr – Incorrect. RBC transfusions must not exceed 4 hours due to the risk of bacterial growth and hemolysis.
B. 6 hr – Incorrect. Blood products should be infused within a maximum of 4 hours to prevent complications.
C. 4 hr – Correct Answer. The maximum infusion time for packed RBCs is 4 hours to reduce the risk of bacterial contamination and infection.
D. 2 hr – Incorrect. While blood is often infused within 2 hours, the maximum safe limit is 4 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Loosen the patient's restrictive clothing – This helps prevent airway obstruction and allows for better chest expansion during the seizure.
B. Open the patient’s jaws to insert an oral airway – Never attempt to force open the mouth during a seizure, as it can cause injury.
C. Restrain the patient to prevent injury – Restraining can cause further harm and should be avoided. Instead, clear the area around the patient to prevent injury.
D. Place patient in high-Fowler’s position – The patient should be placed in a side-lying position to prevent aspiration, not high-Fowler’s.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Answer: The nurse should first address the patient’s oxygen saturation followed by the patient’s hypotension.
Rationale:
1st Priority: Oxygen Saturation → The client’s oxygen saturation has dropped to 88% on room air, which is below the expected range (typically ≥95% in healthy individuals). Hypoxia must be addressed immediately to prevent further complications. The nurse should apply supplemental oxygen and reassess respiratory status.
2nd Priority: Hypotension → The client’s blood pressure has dropped to 94/59 mmHg, which is significantly lower than the earlier reading of 102/76 mmHg. This may contribute to dizziness and syncope. The nurse should monitor for signs of hemodynamic instability, assess for ongoing blood loss (related to heavy menstrual bleeding), and anticipate interventions such as IV fluids or further evaluation for anemia-related hypotension.
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