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.

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

Administer the unit of packed RBCs over 1 hr.

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

Answer and Explanation

The Correct Answer is D

Rationale:

A. "Initiate venous access with a 21-gauge needle." For blood transfusions, it is recommended to use a larger gauge needle, 18-20 gauge, to allow for proper blood flow and reduce the risk of hemolysis. A 21-gauge needle is too small for optimal transfusion.

B. "Obtain the client's first set of vital signs 1 hr after initiating the transfusion." The first set of vital signs should be obtained immediately before starting the transfusion, and then monitored every 15 minutes to detect any early signs of a transfusion reaction.

C. "Administer the unit of packed RBCs over 1 hr." The unit of packed RBCs should be administered over 4 hours to reduce the risk of transfusion reactions and allow for optimal oxygen-carrying capacity. Infusing blood too quickly can cause complications such as volume overload or reactions.

D. "Use Y tubing with 0.9% sodium chloride when administering the transfusion." Y tubing is commonly used for blood transfusions to allow for the infusion of normal saline (0.9% sodium chloride) alongside the blood product. This helps maintain the flow of the transfusion and reduces the risk of clot formation while flushing the line.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Apply a sequential compression device: A sequential compression device (SCD) is used to prevent deep vein thrombosis (DVT), not foot drop. It does not provide the necessary support for preventing foot drop, which results from muscle weakness or paralysis after a CVA.

B. Use padded splints: Padded splints help maintain the foot in a neutral position, which is essential in preventing foot drop. Foot drop occurs due to weakness of the dorsiflexor muscles, and splints can prevent the foot from falling into an abnormal position, reducing the risk of deformities.

C. Elevate the extremity above the heart: Elevating the extremity above the heart is typically done to reduce edema, not to prevent foot drop. While elevating the limb can help with swelling, it does not address the muscle weakness that causes foot drop in post-CVA patients.

D. Reposition the client every 2 hr: Repositioning the client every 2 hours is important for preventing pressure ulcers and promoting circulation. However, it is does not prevent foot drop, which requires targeted interventions such as splints or exercises to maintain proper foot positioning.

A. Place the client in the Trendelenburg position. B. Clamp the catheter above the specimen port. C. Use a 3-mL syringe to perform the catheter irrigation. D. Inject the irrigation solution slowly into the catheter.

Correct Answer is D

Explanation

Rationale:

A. "Place the client in the Trendelenburg position." The Trendelenburg position is not required for intermittent irrigation. This position is typically used to increase venous return in certain medical conditions, not for urinary catheter irrigation.

B. "Clamp the catheter above the specimen port." Clamping the catheter above the specimen port is not necessary for irrigation. Clamping could cause urine retention or discomfort, which is not recommended during intermittent irrigation.

C. "Use a 3-mL syringe to perform the catheter irrigation." A 3-mL syringe is too small for irrigating a catheter. Typically, a larger syringe (e.g., 30-50 mL) is used to administer the irrigation solution effectively.

D. "Inject the irrigation solution slowly into the catheter.” The irrigation solution should be injected slowly to avoid bladder distention and to ensure the solution flows through the catheter without causing discomfort.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has had a recent cerebrovascular accident (CVA). Which of the following actions should the nurse include in the plan of care to decrease the client's risk for footdrop?

Correct Answer is B

Explanation

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take when performing a closed intermittent irrigation?

Correct Answer is D

Explanation

A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is teaching a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching?

Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

A nurse is caring for a client who has pneumonia caused by Haemophilus influenzae type B. Which of the following types of isolation precautions should the nurse implement?

A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?

A nurse finds a client in bed, unresponsive and breathing. Which of the following actions should the nurse take first?

A nurse is caring for a client who has cancer. The client tells the nurse, "I would prefer to try vitamins and minerals instead of chemotherapy." Which of the following responses should the nurse make?

A home health nurse is reviewing safety with the family of a client who uses home oxygen therapy. Which of the following information should the nurse include?