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?
Prime the IV tubing with lactated Ringer's.
Use a 24-gauge IV catheter for the transfusion.
Ensure that the IV tubing has an in-line filter.
Prepare to change the tubing at least every 2 hr.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A nurse administers the wrong medication to a client. – This is an example of negligence, as it represents a failure to follow the standard of care, potentially causing harm to the client. Nurses are expected to follow the "five rights" of medication administration to prevent errors.
B. A nurse applies wrist restraints to a client in violation of the facility's restraint use policy. – This is an example of false imprisonment, not negligence, as it involves restricting a client’s movement without proper justification.
C. A nurse touches a client in an offensive manner. – This is an example of battery, which is the intentional act of touching someone without their consent in a harmful or offensive way.
D. A nurse shares information about a client with family members without the client's consent. – This is an example of a breach of confidentiality, violating HIPAA regulations.
Correct Answer is B
Explanation
A. Chronic grief Chronic grief is prolonged and intense, lasting for an extended period without resolution. The client's symptoms suggest a different grief response.
B. Masked grief Masked grief occurs when a person experiences physical symptoms or maladaptive behaviors that they may not initially recognize as being related to their loss. The client's headaches, indigestion, and heart palpitations are physical manifestations of their grief.
C. Exaggerated grief Exaggerated grief involves intense emotions and self-destructive behaviors, such as depression, substance abuse, or suicidal thoughts, rather than primarily physical symptoms.
D. Delayed grief Delayed grief occurs when a person suppresses their emotions and does not experience grief reactions until later, often triggered by another event. The client's current physical symptoms suggest an ongoing response rather than a delayed one.
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