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 nurse should not inform the provider that the PCA is not providing adequate pain relief, as this is not true based on the client's pain rating of 2 out of 10.
B. The nurse should not ask the provider for a prescription to decrease the continuous rate, as this may compromise the client's pain relief and comfort.
C. The client should be encouraged to use the PCA pump before the pain becomes severe, as this will provide better pain control and reduce the risk of side effects.
D. Instructing the caregiver to push the button without the client's request may lead to overmedication and potential respiratory depression.

A. Lean patient against the bedside table. B. Splint the abdomen with a pillow. C. Support the patient's back. D. Offer an antitussive.

Correct Answer is B

Explanation

A. Leaning against a bedside table does not provide adequate support or comfort for coughing.
B. Splinting the abdomen with a pillow supports the incision site and reduces pain, making it easier for the patient to cough effectively.
C. Supporting the patient's back is helpful but not as effective as abdominal splinting for reducing pain during coughing.
D. Offering an antitussive is not appropriate as it suppresses coughing, which is needed to clear secretions postoperatively.

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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 caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

What technique will the nurse implement to assist the postoperative patient to cough?

Correct Answer is B

Explanation

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