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 C
Explanation
A. Incorrect. Regular insulin (short-acting) and Humulin N (intermediate-acting) can be mixed.
B. Incorrect. Regular insulin and Novolin N are compatible.
C. Correct. Lantus (glargine) is a long-acting insulin that should never be mixed with other insulins.
D. Incorrect. Humulin R (short-acting) and Novolin N (intermediate-acting) can be mixed.
Correct Answer is B
Explanation
A. Impaired immunity. – Incorrect. While anemia may weaken overall health, hemoglobin levels of 10 g/dL do not significantly affect immune function.
B. Hypoxia. – Correct Answer. Hemoglobin carries oxygen in the blood, and low levels can lead to decreased oxygen delivery to tissues, causing hypoxia.
C. Fluid retention. – Incorrect. Anemia does not directly cause fluid retention.
D. Prolonged bleeding. – Incorrect. While severe anemia can be associated with bleeding disorders, a hemoglobin level of 10 g/dL does not significantly impair clotting.
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