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 will weigh myself at different times of the day to monitor fluid retention.": Weighing at different times of day does not provide accurate information about fluid status because daily fluctuations can vary with meals and activity. Clients should weigh themselves at the same time each morning to detect true changes in fluid retention.
B. "I should take ibuprofen for a headache.": Ibuprofen can cause sodium and water retention, increasing the workload on the heart and worsening heart failure. Clients should avoid NSAIDs and use safer alternatives such as acetaminophen for pain relief to prevent exacerbation of symptoms.
C. "I should be able to have a conversation while exercising.": This indicates understanding of safe activity levels, as moderate exercise should allow the client to talk without significant breathlessness. Using the “talk test” helps prevent overexertion and supports appropriate activity tolerance in heart failure management.
D. "I can have a total of 4 grams of sodium each day.": A limit of 4 grams of sodium per day is too high for clients with heart failure. The recommended amount is 2 grams or less to reduce fluid retention and prevent decompensation. A higher sodium intake could worsen symptoms and lead to hospitalization.
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.
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.