A nurse is preparing to administer 2 units of packed RBCs to a client.
Which of the following actions should the nurse take?
Transfuse each unit of blood over 5 hr.
Change the IV tubing after each unit of blood is transfused.
Prime the tubing with 0.9% sodium chloride.
Administer the blood through a 22-gauge intravenous catheter.
The Correct Answer is C
When administering packed RBCs, the tubing should be primed with 0.9% sodium chloride.
Transfusing each unit of blood over 5 hours (choice A) is not recommended as it may increase the risk of bacterial growth.
Packed RBCs should be transfused over 2 to 3 hours.
Changing the IV tubing after each unit of blood is transfused (choice B) is not necessary.
Administering the blood through a 22-gauge intravenous catheter (choice D) may not be appropriate as a larger gauge catheter is typically used for blood transfusions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The priority topic for the nurse to review with the client is monitoring changes in weight.
A sudden weight gain may mean that the client’s heart failure is getting worse and they should call their doctor if they have a sudden weight gain, such as more than 2 to 3 pounds in a day or 5 pounds in a week.
Choice A is wrong because while daily exercise is important for overall health, it is not the priority topic for the nurse to review with the client.
Choice B is wrong because while daily sodium restrictions are important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Choice C is wrong because while monitoring fluid intake is important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Correct Answer is C
Explanation
Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
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