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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Rationale:

Prolonged rupture of membranes: Membranes ruptured for over 24 hours (28 hr), increasing the risk for ascending bacterial infections such as endometritis or chorioamnionitis.
Prenatal anemia: Anemia reduces immune function and tissue oxygenation, making the client more susceptible to postpartum infections, including uterine and systemic infections.
Polyhydramnios: Excessive amniotic fluid causes uterine overdistension, which weakens uterine contractility and increases the risk of atony and postpartum hemorrhage.
High parity: Repeated stretching of the uterus in grand multiparity reduces muscle tone, making the uterus less responsive to postpartum contraction and more prone to atony.

A. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field. B. Hold the sterile package in his dominant hand and open the top flap of the package toward his body. C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field. D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container.

Correct Answer is A

Explanation

Rationale:

A. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Dropping sterile items from a height of about 6 to 12 inches prevents contamination by keeping hands outside the sterile field and ensuring the item lands safely without touching nonsterile surfaces.

B. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to maintain sterility and prevent the arm from crossing over the sterile field, which would risk contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 2.5 cm (1 inch) of the sterile field is considered contaminated. Placing items only 0.5 inches inside this border would place them within the contaminated zone, risking sterile field compromise.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: While the bottle should not touch the sterile field, it must be close enough to pour without splashing, and the sterile container must be inside the sterile field.

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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

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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