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.

Answer and Explanation

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.

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Correct Answer is ["B","D","E","F"]

Explanation

A. Respiratory alkalosis: The client’s arterial pH is 7.30, indicating acidemia rather than alkalemia. Respiratory alkalosis is not expected in hyperglycemic crises; instead, metabolic acidosis may develop due to ketone accumulation and dehydration.

B. Hypotension: The client’s blood pressure is 96/65 mm Hg, which is lower than normal, likely related to dehydration from osmotic diuresis caused by severe hyperglycemia. Ongoing fluid loss increases the risk of hypotension, making it an important complication to monitor and manage promptly.

C. Septic shock: While the client has a recent history of bronchitis and pneumonia, there is no current evidence of infection such as fever, tachypnea, or elevated WBCs. Although infection could precipitate hyperglycemia, septic shock is not an immediate complication indicated by the current findings.

D. Cardiac arrhythmias: The client has a potassium level of 5.5 mEq/L, which is elevated. Hyperkalemia increases the risk of cardiac arrhythmias, especially in combination with dehydration and acidosis, making close cardiac monitoring necessary.

E. Renal failure: Elevated BUN (21 mg/dL) and creatinine (1.7 mg/dL) suggest impaired renal perfusion or acute kidney injury secondary to dehydration from osmotic diuresis. The client is at risk of progression to renal failure if fluid and electrolyte imbalances are not corrected.

F. Cerebral edema: Cerebral edema is often caused by an overly rapid drop in effective serum osmolarity during treatment, primarily when blood glucose is lowered too quickly. The rapid shift in fluid from the bloodstream to the brain cells can cause swelling.

Correct Answer is ["22"]

Explanation

Convert the client’s weight from pounds to kilograms

Weight (kg) = Weight (lb) ÷ 2.2

Weight (kg) = 160 ÷ 2.2

Weight (kg) = 72.73 kg

Calculate the daily protein requirement

Protein Requirement (g) = Weight (kg) × RDA (g/kg)

Protein Requirement = 72.73 × 0.3

Protein Requirement = 21.82 g

Round to the nearest whole number

= 22 g

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department. The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Correct Answer is ["B","D","E","F"]

Explanation

Correct Answer is ["22"]

Explanation

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