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.

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

Administer the unit of packed RBCs over 1 hr.

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

Answer and Explanation

The Correct Answer is A

Practice standards indicate blood should be infused through a 20-gauge or larger catheter to prevent hemolysis [destruction] of red blood cells. Y tubing with 0.9% sodium chloride is used to administer blood products is not necessary. A unit of packed RBCs should be administered over 2 to 4 hours, unless otherwise ordered by the provider, to reduce the risk of fluid overload and transfusion reactions . The client's vital signs should be obtained before, during (15 minutes after starting and every hour thereafter), and after the transfusion to monitor for any signs of adverse reactions.

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Correct Answer is A

Explanation

A history of inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, is a risk factor for colorectal cancer . These conditions cause chronic inflammation and damage to the cells lining the colon and rectum, which may increase the likelihood of DNA mutations and cancer development. A diet high in fiber may help lower the risk of colorectal cancer by promoting regular bowel movements and reducing exposure to toxins. Age 46 years is not a significant risk factor, as most cases of colorectal cancer occur in people older than 50. BMI of 24 is within the normal range and does not indicate obesity, which is another risk factor for colorectal cancer.

A. Pupillary dilation B. Decorticate posturing C. Altered level of consciousness D. Cheyne-Stokes respirations

Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

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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

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