A nurse is planning to administer a unit of PRBCS for a client. Which of the following actions should the nurse plan to take?

Stay with the client for the first 10 min after starting the transfusion.

Flush the transfusion tubing with 5% dextrose in water.

Ensure 2 nurses check the label on the unit of blood.

Administer the blood transfusion over 1 hr.

Answer and Explanation

The Correct Answer is C

A.   The correct actions to take include staying with the client for the first 15-30 minutes after starting the transfusion, not just the first 10 minutes, to monitor for any adverse reactions.
B.   It is also crucial to use 0.9% sodium chloride solution, not 5% dextrose in water, to flush the transfusion tubing.
C.   It is a standard practice to have two nurses check the blood unit label to verify the correct blood type and compatibility before administration.
D.   The transfusion should not be rushed over 1 hour; instead, it should be administered over a period of 2-4 hours, depending on the patient's condition and the volume of PRBCs to be transfused.

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Correct Answer is C

Explanation

A. This is a good method to gather feedback but does not directly assess the client's ability to perform the taught skills.
B. This is important to identify knowledge gaps but does not assess the client's ability to perform the skills.
C. This is the most direct way to assess the client's ability to perform the taught skill and ensures that the client has retained the information.
D. While important, vital signs do not directly assess the effectiveness of home care teaching.

A. Turn the patient's head to suction more effectively. B. Administer an antidysrhythmic medication. C. Stop suctioning, allow patient to rest and reassess the need to continue suctioning. D. Obtain a cardiology consult.

Correct Answer is C

Explanation

A. Changing the patient's head position during suctioning can increase discomfort and hypoxia.
B. This is premature. The tachycardia may be a temporary response to the suctioning procedure.
C. The increased heart rate is likely a response to the stimulation of suctioning. Stopping the procedure allows the patient to recover and reassessment can determine if further suctioning is necessary.
D. This is excessive and not necessary at this time.

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A nurse is planning to administer a unit of PRBCS for a client. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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