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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect → Weight gain (even if minor) can indicate poor glucose control, especially if linked to fluid retention or insulin resistance.
B. Regular ophthalmology exams are crucial for early detection of diabetic retinopathy, a leading cause of blindness in diabetes. Scheduling an eye appointment demonstrates proactive disease management.
C. Incorrect → A Hemoglobin A1c of 8.1% is above the target range (typically <7% for diabetics) and indicates poor blood glucose control over the past 2-3 months.
D. Incorrect → A reddened area on the sole of the foot suggests early signs of diabetic foot complications and possible neuropathy or poor circulation, requiring intervention.
Correct Answer is B
Explanation
A. Give the patient access to a video about diabetes. – Incorrect. Educational materials are helpful but should be provided after assessing the patient's current knowledge level.
B. Determine what the patient knows about managing diabetes. – Correct Answer. The first step in teaching is to assess the patient's baseline knowledge to tailor the education to their needs.
C. Establish short-term, realistic goals for the patient. – Incorrect. Goal-setting is important but should come after assessing the patient’s knowledge and readiness to learn.
D. Evaluate the effectiveness of the patient's admission teaching plan. – Incorrect. The nurse should first determine what new information needs to be taught before evaluating previous teaching.
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