A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
When the client states he is ready to start the infusion
As soon as the nurse can prepare the client and the administration set
2 hours after obtaining blood from the blood bank
When the client has finished eating lunch
The Correct Answer is B
A. When the client states he is ready to start the infusion:
While it's important to consider the client's readiness and cooperation, the timing of the infusion should not solely depend on the client's statement. The priority is to start the infusion promptly after receiving the packed red blood cells (PRBCs) from the blood bank to ensure their safety and effectiveness.
B. As soon as the nurse can prepare the client and the administration set:
This choice is the correct answer. After receiving the unit of PRBCs from the blood bank at 1130, the nurse should begin the infusion as soon as possible after preparing the client (ensuring the correct patient, verifying the blood type compatibility, obtaining informed consent, etc.) and the administration set (priming the IV tubing, checking for any leaks, etc.). Prompt administration helps prevent delays that could compromise the quality of the blood product.
C. 2 hours after obtaining blood from the blood bank:
Waiting for 2 hours before starting the infusion is too long and could exceed the recommended timeframe for administering PRBCs after obtaining them from the blood bank. Delaying the infusion for such an extended period could impact the viability and safety of the blood product.
D. When the client has finished eating lunch:
The timing of the client's meal is not a factor in determining when to start the infusion of PRBCs. While it's generally important for the client to have adequate nutrition and hydration, the priority is to administer the blood product promptly after preparation to ensure its efficacy and safety, rather than waiting for unrelated factors such as meal times.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","F"]
Explanation
A. History of smoking:
Smoking is a well-established risk factor for coronary artery disease (CAD). Cigarette smoke contains harmful chemicals that damage blood vessels, promote the formation of atherosclerotic plaques, and increase the risk of blood clots, all of which can lead to CAD, heart attacks, and strokes.
B. Body mass index (BMI) of 20:
While obesity and elevated BMI are risk factors for CAD, a BMI of 20 falls within the healthy weight range for most adults. However, it's important to note that BMI alone may not fully capture an individual's overall cardiovascular risk, as factors like body composition, waist circumference, diet, and physical activity level also contribute to heart health.
C. History of diabetes:
Diabetes, especially type 2 diabetes, is a significant risk factor for CAD. Elevated blood sugar levels over time can damage blood vessels (atherosclerosis), increase inflammation, and contribute to other metabolic abnormalities that raise the risk of heart disease, including heart attacks and peripheral vascular disease.
D. Family history of coronary heart disease:
Having a family history of coronary heart disease (CHD) or premature heart attacks (before age 55 in men or before age 65 in women) increases the risk of developing CAD. Genetic factors play a role in the development of heart disease, and individuals with close relatives affected by CHD have a higher likelihood of developing similar conditions.
E. Female gender:
While gender can influence cardiovascular risk factors and presentation, being female alone is not considered a specific risk factor for CAD. However, women may have different risk profiles or risk factors compared to men, such as hormonal influences (e.g., menopause) and unique symptom presentation for heart disease.
F. Age greater than 45 years for men:
Advancing age is a significant risk factor for CAD, especially for men. Men aged 45 years and older are at increased risk compared to younger age groups due to factors such as the cumulative effects of risk factors over time, hormonal changes, and age-related changes in blood vessels and heart function.
Correct Answer is A
Explanation
A. Monitor weight daily: Daily weight monitoring is a crucial aspect of assessing fluid balance in clients with heart failure. Sudden weight gain can indicate fluid retention, which may be a sign of worsening heart failure. The nurse should instruct the client to weigh themselves at the same time each day, preferably in the morning after emptying the bladder and before eating breakfast, and to report any significant weight changes to their healthcare provider.
B. Assess radial pulses daily: While assessing radial pulses is important for monitoring cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Radial pulse assessment is more related to evaluating cardiac output and peripheral perfusion.
C. Monitor bowel movements: Monitoring bowel movements is not directly related to assessing fluid balance in heart failure. Although changes in bowel habits can sometimes be associated with fluid and electrolyte imbalances, it is not the primary method for assessing fluid balance in this context.
D. Monitor blood pressure daily: While monitoring blood pressure is important for managing hypertension and evaluating cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Blood pressure monitoring is more related to assessing hemodynamic stability and response to medications.
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