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A nurse is preparing to administer an infusion of packed RBCs through a peripheral IV catheter. Which of the following actions should the nurse take?

A.

Prime the IV tubing with lactated Ringer's.

B.

Use a 24-gauge IV catheter for the transfusion.

C.

Ensure that the IV tubing has an in-line filter.

D.

Prepare to change the tubing at least every 2 hr.

Answer and Explanation

The Correct Answer is C

A. Prime the IV tubing with lactated Ringer's. Blood products should only be primed with 0.9% sodium chloride (normal saline) because other solutions (e.g., lactated Ringer's or dextrose solutions) can cause hemolysis.
B. Use a 24-gauge IV catheter for the transfusion. A 24-gauge catheter is too small for a blood transfusion and may cause hemolysis or slow infusion. A large-bore catheter (18–20 gauge) is recommended for optimal flow.
C. Ensure that the IV tubing has an in-line filter. An in-line filter helps remove clots and debris, reducing the risk of transfusion reactions.
D. Prepare to change the tubing at least every 2 hr. Blood tubing should typically be changed after 4 hours or after two units of blood, whichever comes first, to prevent bacterial contamination.


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Related Questions

Correct Answer is A

Explanation

A. "Your family member has the right to refuse care." Every competent adult has the legal and ethical right to make decisions about their own medical treatment, including the right to refuse care, even if it results in death.
B. "To continue treatment, you must be appointed as your family member's health care surrogate." The client is still competent and capable of making their own decisions, so a surrogate is not necessary or legally allowed to override their wishes.
C. "We should discuss different treatment options when your family member is not present." Discussing medical decisions behind the client’s back would be unethical and violate the principle of autonomy.
D. "I can submit your request to the ethics committee." There is no ethical dilemma here, as the client has the right to refuse treatment, and their decision must be respected.

Correct Answer is C

Explanation

A. Temperature of 38° C (100.4° F) A slight fever is not a primary sign of internal bleeding. It could be related to infection or another inflammatory response.
B. Respiratory rate of 10/min Internal bleeding is more likely to cause an increased respiratory rate (tachypnea) due to hypoxia rather than a decreased rate.
C. Heart rate of 112/min Tachycardia (HR >100 bpm) is an early sign of internal bleeding. The body increases the heart rate to compensate for blood loss and maintain perfusion.
D. Blood pressure of 136/88 mm Hg While low blood pressure (hypotension) can indicate severe internal bleeding, this BP is within normal range. However, a sudden drop in BP later would be a concerning sign.

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