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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increasing sodium intake would exacerbate hypernatremia, not correct it. Hypernatremia is characterized by an excess of sodium in the blood, so the goal of treatment is to lower sodium levels, not increase them.
B. Infusing hypotonic IV fluids, such as 0.45% NaCl or D5W (5% dextrose in water), helps to dilute the high sodium concentration in the blood and can assist in correcting hypernatremia. Hypotonic fluids move water into cells and help balance the sodium levels by promoting hydration and lowering the sodium concentration.
C. Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia (elevated potassium levels), not hypernatremia. It works by exchanging potassium for sodium in the gastrointestinal tract and would not address hypernatremia.
D. Implementing a fluid restriction is generally not the best approach for treating hypernatremia. In fact, fluid restriction could worsen hypernatremia by limiting the client's fluid intake and not addressing the sodium imbalance. The primary goal in hypernatremia is usually to rehydrate the patient with appropriate fluids.
Correct Answer is C
Explanation
A. While important for overall patient assessment, it's not the most direct way to monitor for a wound infection.
B. Pain can indicate a wound infection, but it's not as specific as directly inspecting the wound.
C. This is the most direct way to assess for early signs of a wound infection. Redness, swelling, warmth, and drainage are classic signs of infection.
D. Important for overall patient care, but not specifically related to wound infection prevention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.