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 A
Explanation
A. Correct. A platelet count <20,000/μL increases bleeding risk. Checking for occult blood helps detect hidden gastrointestinal bleeding.
B. Incorrect. Hydration is important but does not directly address thrombocytopenia management.
C. Incorrect. While oral hygiene is important, frequent brushing could cause bleeding with low platelets.
D. Incorrect. Monitoring temperature is important for infection risk but does not address bleeding concerns.
Correct Answer is B
Explanation
A. Give potassium intravenously. – The potassium level is 3.7 (within normal range 3.5–5.0), so potassium is not needed yet.
B. Administer D5 NS with the insulin drip. – Correct Answer. Once glucose drops to ≤200 mg/dL, dextrose is added to prevent hypoglycemia while continuing insulin to correct ketoacidosis.
C. Administer 3% NS at 200 mL/hr. – Hypertonic saline is used for severe hyponatremia, which is not the case here.
D. Expect the insulin drip to be discontinued. – The insulin drip is not discontinued until ketoacidosis has fully resolved (when HCO3 > 18, pH > 7.3, and anion gap normalizes).
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