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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Use passive listening techniques during conflict resolution: Passive listening involves minimal engagement and can lead to misunderstandings or missed key concerns. Active listening is more effective in conflict resolution as it validates feelings and clarifies perspectives.
B. Ask closed-ended questions about the conflict: Closed-ended questions limit the depth of responses and may not fully uncover the underlying issues. Open-ended questions encourage dialogue and help reveal the root causes of conflict more effectively.
C. Ensure each individual can respond defensively about the conflict: Allowing or encouraging defensive responses can escalate tension and hinder resolution. A nonjudgmental and respectful environment promotes open communication and constructive problem-solving.
D. Gather individual information regarding the conflict: Collecting information from each party separately allows the nurse manager to understand different perspectives, identify miscommunications, and develop a balanced and informed approach to resolving the conflict.
Correct Answer is B
Explanation
Rationale:
A. Administer the medication as prescribed: Administering amoxicillin to a client with a penicillin allergy can result in serious allergic reactions, including rash, hives, or anaphylaxis. Amoxicillin is a penicillin derivative, it is contraindicated in patients with penicillin allergies.
B. Discuss the prescription with the health care provider: The nurse must clarify potentially harmful prescriptions directly with the provider. This ensures patient safety by verifying if the medication should be changed, considering the client’s documented allergy to penicillin.
C. Call the pharmacist for clarification of the medication contraindications: While pharmacists can verify drug classes and potential reactions, they do not have the authority to discontinue or modify a prescription. Only the healthcare provider can make necessary changes to an order.
D. Place an incident report in the medical record: Incident reports are meant for internal documentation and are never placed in the client’s medical record. Since the error has not occurred yet, prevention through provider consultation is the priority action.
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