A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?
Check that the client has a small gauge IV catheter in place.
Check the blood product's compatibility with the client's blood type.
Prime the client's primary IV tubing with lactated Ringer's.
Confirm the identity of the client with the blood bank technician.
The Correct Answer is B
A. Check that the client has a small gauge IV catheter in place.
Blood transfusions require a large-bore IV catheter (18-20 gauge) to prevent hemolysis and ensure efficient infusion. A small gauge IV (such as 22-24G) is not appropriate for PRBCs as it can slow the infusion and damage red blood cells.
B. Check the blood product's compatibility with the client's blood type: Before administering packed red blood cells (PRBCs), the nurse must verify blood compatibility to prevent a hemolytic transfusion reaction, which can be life-threatening.
C. Prime the client's primary IV tubing with lactated Ringer’s.
Only normal saline (0.9% NaCl) should be used to prime the IV tubing for a blood transfusion. Lactated Ringer’s and dextrose solutions can cause hemolysis and clotting of the blood product.
D. Confirm the identity of the client with the blood bank technician. While verifying the blood product is critical, the nurse should confirm the client’s identity at the bedside with another licensed nurse, not the blood bank technician. This ensures that the right blood is given to the right client following facility protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Tell me more about your partner.":
While understanding the client's feelings about their partner is important, the immediate concern is the client's statement expressing a desire to die. Therefore, focusing on the client's thoughts about self-harm (Option B) takes precedence in ensuring their safety.
B. "Have you thought about harming yourself?":
This response is appropriate because it directly addresses the client's statement expressing a desire to die. It opens a dialogue about the client's thoughts and intentions related to self-harm, allowing the nurse to assess the client's risk and initiate appropriate interventions.
C. "Why did you stop taking your medication?":
While understanding the reasons behind medication non-compliance is important, the immediate concern is the client's current statement indicating suicidal ideation. Exploring the client's medication adherence can be addressed after addressing the acute safety concern.
D. "You should discuss these feelings with your provider.":
This response might be seen as avoiding the client's immediate expression of distress. It is important for the nurse to directly assess the client's risk and initiate appropriate interventions rather than deferring the responsibility to another healthcare provider at this moment.
Correct Answer is C
Explanation
A. Exercise 1 hr before bedtime:
While regular exercise is beneficial for overall health, exercising close to bedtime may actually interfere with sleep. It is better to exercise earlier in the day
B. Drink a cup of hot cocoa before bedtime:
While a warm beverage like hot cocoa may be soothing for some individuals, it contains caffeine, which can interfere with sleep. Caffeine consumption, especially close to bedtime, is generally discouraged for those experiencing insomnia.
C. Eat a light carbohydrate snack before bedtime: can help promote sleep. Carbohydrates increase the availability of tryptophan, an amino acid that contributes to the production of serotonin (a neurotransmitter associated with relaxation and sleep).However, the snack should be light and not too heavy to avoid discomfort or indigestion during sleep
.
D. Take a 30-min nap daily:
Taking a 30-minute nap daily may not be the most effective intervention for insomnia. Napping during the day can interfere with nighttime sleep, especially if it's taken too close to bedtime. Short naps earlier in the day are generally recommended if needed.
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