A nurse is preparing to initiate a transfusion of packed RBC for a patient who has anemia. Which of the following actions should the plan to nurse take?

Infuse the transfusion at a rate of 200 mL/hr.

Check the patient's vital signs every hour during the transfusion.

Leave the patient 5 minutes after beginning the transfusion.

Flush the blood tubing with dextrose 5% in water.

Answer and Explanation

The Correct Answer is B

A. Infuse the transfusion at a rate of 200 mL/hr. – Incorrect. The initial infusion should be slow (e.g., 75-100 mL/hr) to monitor for reactions.

B. Check the patient's vital signs every hour during the transfusion. – Correct Answer. Frequent monitoring is necessary to detect adverse reactions, such as fever or hypotension.

C. Leave the patient 5 minutes after beginning the transfusion. – Incorrect. The nurse should remain with the patient for the first 15 minutes, as most transfusion reactions occur early.

D. Flush the blood tubing with dextrose 5% in water. – Incorrect. Only normal saline should be used to flush blood tubing, as dextrose can cause hemolysis.

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Correct Answer is D

Explanation

A. Rowing. – Incorrect. Rowing can strain the lower back.

B. Tennis. – Incorrect. Twisting motions in tennis can exacerbate back pain.

C. Canoeing. – Incorrect. Similar to rowing, canoeing may strain the lower back.

D. Swimming. – Correct Answer. Water-based exercises provide low-impact movement and reduce strain on the spine, making swimming the best choice.

A. Dextrose 5% in 0,45% sodium chloride IV B. Oral hypoglycemic medications C. Glucocorticoid medications D. 0.9% sodium chloride IV

Correct Answer is D

Explanation

A. Dextrose 5% in 0.45% sodium chloride IV. – Incorrect. Dextrose is given later, after blood glucose drops below 250 mg/dL to prevent hypoglycemia.

B. Oral hypoglycemic medications. – Incorrect. DKA requires IV insulin, not oral medications.

C. Glucocorticoid medications. – Incorrect. Glucocorticoids can worsen hyperglycemia by increasing blood sugar.

D. 0.9% sodium chloride IV. – Correct Answer. Fluid resuscitation with normal saline is the first priority to correct hypovolemia caused by osmotic diuresis in DKA.

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Nursing Test Bank

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