A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take?

Check the unit of blood with an assistant personal (AP).

Plan to infuse the unit of blood over 6 hr.

Remain with the client for the first 15 minutes of the transfusion.

Pre-medicate the client with an antiemetic.

Answer and Explanation

The Correct Answer is C

A. The blood must be checked by two licensed professionals, not an assistant personal (AP).
B. Blood should be infused within 4 hours to reduce the risk of bacterial contamination.
C. The nurse should remain with the client for the first 15 minutes of the transfusion to monitor for any immediate adverse reactions.
D. Pre-medicating with an antiemetic is not a standard practice unless specifically indicated by the client's history or condition.

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Correct Answer is C

Explanation

A. The maturation phase is the final phase of wound healing and involves the strengthening and remodeling of collagen fibers.
B. The proliferation phase is the second phase of wound healing, characterized by the formation of new tissue and blood vessels.
C. The inflammation phase is the first phase of wound healing, during which the body's initial response to injury involves hemostasis and inflammation. This phase includes vasodilation, increased permeability of blood vessels, and the influx of white blood cells to clean the wound.
D. The remodeling phase is another term for the maturation phase, the final phase of wound healing.

A. Full thickness skin loss with visible bone B. Full thickness skin loss with visible adipose tissue. C. Partial-thickness skin loss with red tissue in wound bed D. Intact skin with localized erythema

Correct Answer is D

Explanation

A. Full thickness skin loss with visible bone describes a stage 4 pressure injury.
B. Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury.
C. Partial-thickness skin loss with red tissue in the wound bed describes a stage 2 pressure injury.
D. Intact skin with localized erythema (redness) that does not blanch when pressure is applied is characteristic of a stage 1 pressure injury.

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A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to teach a group of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse plan to discuss?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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