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?
Administer the unit of packed RBCs over 1 hr.
Obtain the client's first set of vital signs 1 hr after initiating the transfusion.
Use Y tubing with 0.9% sodium chloride when administering the transfusion.
Initiate venous access with a 21-gauge needle.
The Correct Answer is C
A. Administer the unit of packed RBCs over 1 hr: Transfusing packed RBCs too quickly increases the risk of fluid overload and cardiovascular complications. Standard practice is to administer the unit over 2 to 4 hours, with careful monitoring for adverse reactions.
B. Obtain the client's first set of vital signs 1 hr after initiating the transfusion: Vital signs should be obtained immediately before starting the transfusion, then monitored closely during the first 15 minutes, when most acute transfusion reactions occur. Waiting an hour could delay recognition of complications.
C. Use Y tubing with 0.9% sodium chloride when administering the transfusion: Y tubing with normal saline is the correct method for administering packed RBCs. Saline maintains patency of the line and prevents incompatibility reactions, as other IV solutions can cause hemolysis or chemical reactions with the blood product.
D. Initiate venous access with a 21-gauge needle: A 21-gauge needle is too small for safe administration of packed RBCs, as it can cause hemolysis. A larger gauge needle, typically 18–20 gauge, is recommended to ensure smooth transfusion and minimize cell damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “I seem to be bruising more easily,”: Easy bruising is not a typical adverse effect of lisinopril. Bruising may indicate a hematologic issue or another medication effect, but it is unrelated to ACE inhibitor therapy.
B. "I have to urinate frequently.": Increased urination is not commonly associated with lisinopril. Diuretics, rather than ACE inhibitors, are more likely to cause polyuria. This statement does not indicate an adverse effect of lisinopril.
C. "I have a nagging, dry cough.": A persistent, dry cough is a well-known adverse effect of ACE inhibitors like lisinopril. It occurs due to the accumulation of bradykinin in the respiratory tract, and it can be bothersome enough to require medication adjustment or substitution.
D. "I have a heightened sense of taste.": Altered taste perception is not a common adverse effect of lisinopril. While some medications can affect taste, this is not characteristic of ACE inhibitors and is unlikely to be related to the client’s current therapy.
Correct Answer is A
Explanation
A. "Wear cotton rather than nylon socks.": Cotton socks help keep the feet dry by absorbing moisture, reducing the risk of fungal infections and skin breakdown. They also allow better air circulation than nylon, which can trap moisture and increase friction. This instruction supports protective foot care for clients with diabetes.
B. "Use a heating pad to keep your feet warm at night.": Heating pads should be avoided because clients with diabetes may have peripheral neuropathy and reduced sensation. Using heat sources increases the risk of burns or skin injury without the client realizing it, making this unsafe for foot care.
C. "Wear loose fitting slippers around the house.": Loose footwear can cause friction, slipping, and inadequate support, increasing the risk of injury. Diabetic clients should wear well-fitting, closed-toe shoes to protect the feet from trauma and prevent skin breakdown.
D. "Wash your feet twice per day with antibacterial soap and hot water.": Hot water can burn insensate feet, and antibacterial soaps can dry and irritate the skin. Clients should wash their feet once daily with warm water and mild soap to maintain skin integrity while avoiding injury or excessive dryness.
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