A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

Assess the client's lung sounds prior to the infusion.

Infuse the blood over 4 hr.

Verify with another nurse that the unit of blood is compatible with the client's blood type

Prime the infusion tubing with 0.45% sodium chloride

Don sterile gloves to prepare the blood administration setup.

Answer and Explanation

Correct Answer : A,B,C

Rationale:

A. Assess the client's lung sounds prior to the infusion: Pre-transfusion assessment of lung sounds is essential to detect any baseline abnormalities and to monitor for fluid overload or transfusion-related lung complications such as transfusion-associated circulatory overload.

B. Infuse the blood over 4 hr: Older adults are at increased risk for fluid overload, so transfusing packed RBCs slowly over 4 hours is appropriate and safer, as long as the blood is completely administered within the maximum 4-hour window from removal from refrigeration.

C. Verify with another nurse that the unit of blood is compatible with the client's blood type: A dual verification process is mandatory to ensure safe administration. The nurse must check the client’s ID, blood type, unit number, and expiration date with another licensed professional before initiating the transfusion.

D. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime and flush blood transfusion tubing. Hypotonic solutions like 0.45% sodium chloride can cause hemolysis and should never be used with blood products.

E. Don sterile gloves to prepare the blood administration setup: Sterile gloves are not necessary for setting up a blood transfusion. Clean gloves are sufficient for handling equipment and initiating IV therapy, following standard precautions.

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Correct Answer is A

Explanation

Rationale:

A. "I should avoid over-the-counter medications that contain alcohol.": Disulfiram causes an unpleasant reaction when alcohol is consumed, even in small amounts. Clients must avoid alcohol-containing products such as certain cough syrups, mouthwashes, and topical solutions to prevent serious adverse effects like flushing, nausea, and hypotension.

B. "I will need to get a monthly injection of this medication.": Disulfiram is an oral medication taken daily, not administered via monthly injection. The injectable form is associated with other medications used in substance use disorder treatment, such as naltrexone.

C. "My provider wants me to take this medication for 2 weeks before I try to quit drinking.": Disulfiram is intended for clients who have already stopped drinking. It is not used to initiate abstinence but to maintain it by discouraging alcohol use through aversive effects.

D. "I will plan to continue taking this medication for at least 5 years.": The duration of disulfiram therapy varies based on the client’s progress and treatment plan. Long-term use beyond 1–2 years is uncommon and typically guided by continued risk of relapse and provider judgment.

A. Check for a disconnection in the ventilator tubing. B. Assess the ET for a cuff leak. C. Verify the placement of the ET D. Check for a kink in the ventilator tubing. E. Suction the ET to remove secretions

Correct Answer is ["D","E"]

Explanation

Rationale:

A. Check for a disconnection in the ventilator tubing: A disconnection typically causes a low-pressure alarm, not an increase in peak airway pressure, and would not be the appropriate first response in this case.

B. Assess the ET for a cuff leak: A cuff leak would decrease airway pressure, potentially causing a low-pressure alarm. It is not associated with increased peak airway pressure alarms.

C. Verify the placement of the ET: ET tube misplacement can lead to ventilation issues, but it does not directly cause increased peak pressures unless malposition leads to obstruction, which would be less common.

D. Check for a kink in the ventilator tubing: A kink or obstruction in the tubing increases airway resistance and can cause high peak airway pressure alarms. Resolving the kink can restore normal pressure.

E. Suction the ET to remove secretions: Mucus plugging or secretion buildup increases resistance in the airway, raising peak pressures. Suctioning helps alleviate the obstruction and reduce alarm triggers.

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A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing medication teaching about disulfiram for a client who has alcohol use disorder. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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