A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?
Administer the transfusion through a 25-gauge saline lock.
Administer the plasma immediately after thawing.
Transfuse the plasma over 4 hr.
Hold the transfusion if the client is actively bleeding.
The Correct Answer is B
A) Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B) Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C) Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D) Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) This is not a standard intervention for bladder spasms post-TURP.
B) Securing the urinary catheter to the abdomen does not address the immediate issue of potential catheter blockage.
C) Performing an intermittent bladder irrigation using sodium chloride is appropriate in this case. This is because bladder spasms and a scant amount of fluid in the urinary drainage bag may indicate a blockage in the catheter. Intermittent bladder irrigation can help to remove any clots or debris that may be causing the blockage.
D) Encouraging the client to urinate is not applicable as the client cannot urinate normally due to the surgery.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}
Explanation
A) Coughing is not directly related to the client's condition as described in the scenario.
B) Keeping the client's head in a midline position is anticipated to maintain an open airway and prevent further complications, particularly after a cerebrovascular accident.
C) Elevating the head of the bed is anticipated as it can help improve respiratory function and reduce intracranial pressure, which is beneficial given the client's history of cerebrovascular accident and current restlessness and agitation.
D) Assisting the client to the bathroom is contraindicated due to the client's current unresponsiveness and risk of falls; a bedpan or catheter may be more appropriate.
E) Initiating seizure precautions is anticipated because the client's Glasgow Coma Scale score indicates a decreased level of consciousness, which could predispose them to seizures, especially with a history of cerebrovascular accident.
F) Decreasing oxygen to 1.5 L/min via nasal cannula is contraindicated given the client's decreased oxygen saturation levels; instead, the nurse should anticipate the need to maintain or increase oxygen to ensure adequate tissue perfusion.
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