A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take?

Initiate venous access with a 21-gauge needle.

Obtain the client's first set of vital signs 1 hr after initiating the transfusion.

Administer the unit of packed RBCs over 1 hr.

Use Y tubing with 0.9% sodium chloride when administering the transfusion.

Answer and Explanation

The Correct Answer is D

Rationale:

A. "Initiate venous access with a 21-gauge needle." For blood transfusions, it is recommended to use a larger gauge needle, 18-20 gauge, to allow for proper blood flow and reduce the risk of hemolysis. A 21-gauge needle is too small for optimal transfusion.

B. "Obtain the client's first set of vital signs 1 hr after initiating the transfusion." The first set of vital signs should be obtained immediately before starting the transfusion, and then monitored every 15 minutes to detect any early signs of a transfusion reaction.

C. "Administer the unit of packed RBCs over 1 hr." The unit of packed RBCs should be administered over 4 hours to reduce the risk of transfusion reactions and allow for optimal oxygen-carrying capacity. Infusing blood too quickly can cause complications such as volume overload or reactions.

D. "Use Y tubing with 0.9% sodium chloride when administering the transfusion." Y tubing is commonly used for blood transfusions to allow for the infusion of normal saline (0.9% sodium chloride) alongside the blood product. This helps maintain the flow of the transfusion and reduces the risk of clot formation while flushing the line.

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Correct Answer is A

Explanation

Rationale:

A. Poached egg: A poached egg is a good choice for a client with ulcerative colitis as it is easy to digest and does not irritate the gastrointestinal tract. Eggs provide protein without the fiber that could exacerbate diarrhea.

B. Fresh peaches: Fresh peaches are high in fiber, which can aggravate diarrhea in clients with ulcerative colitis. Clients should avoid high-fiber fruits, especially during flare-ups.

C. Whole grain toast: Whole grain toast contains a high amount of fiber, which may irritate the intestines and worsen diarrhea. A low-fiber diet is typically recommended during flare-ups of ulcerative colitis.

D. Oatmeal: Oatmeal is high in fiber, which can be problematic for clients with ulcerative colitis, especially during episodes of diarrhea. It can irritate the digestive system and increase discomfort.

A. "I can have a total of 4 grams of sodium each day." B. "I will weigh myself at different times of the day to monitor fluid retention." C. "I should be able to have a conversation while exercising." D. "I should take ibuprofen for a headache."

Correct Answer is C

Explanation

Rationale:

A. "I can have a total of 4 grams of sodium each day." For clients with heart failure, sodium intake is typically restricted to 2 grams per day to prevent fluid retention and exacerbation of symptoms. 4 grams per day exceeds the recommended.

B. "I will weigh myself at different times of the day to monitor fluid retention." The client should weigh themselves at the same time each day, ideally in the morning after voiding. Weighing at different times can lead to inconsistencies.

C. "I should be able to have a conversation while exercising." Clients with heart failure are encouraged to exercise at a moderate level that allows them to converse comfortably, which helps ensure they are not overexerting themselves and risking heart failure exacerbation.

D. "I should take ibuprofen for a headache." Ibuprofen is contraindicated for clients with heart failure because it can cause fluid retention and negatively impact kidney function. Acetaminophen is a safer alternative for pain relief in these clients.

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A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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