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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Metformin is an oral medication used to treat type 2 diabetes. It should be withheld before and after a procedure that requires IV contrast dye because it can increase the risk of lactic acidosis, a serious condition caused by the buildup of lactic acid in the blood. The other medications are not contraindicated with IV contrast dye and can be given as scheduled.
Correct Answer is A
Explanation
Practice standards indicateblood 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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