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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. "I will not have to get an IV placed."An IV may be placed in some cases, especially if the stress test includes the use of a pharmacological agent (like adenosine or dobutamine) in place of exercise.

B. "I can eat my breakfast before the test."Clients are typically instructed to fast for at least 3 hours before the exercise stress test. Eating could interfere with accurate test results and the ability to safely exercise. The client should not eat right before the test.

C. "I must not drink my hot chocolate in the morning."Caffeine can interfere with the results of the exercise stress test by increasing heart rate and potentially masking abnormal responses to exercise. Therefore, the client should avoid caffeine (including hot chocolate) before the test.

D. "I can wear the clothes I would wear to the office."The client should wear comfortable clothing and shoes that allow for physical activity and movement, such as athletic wear. Office attire may not be suitable for the physical exertion required during the exercise stress test.

A. Relieve client symptoms B. Extend survival C. Improve functional status D. Prevent endocarditis E. Limit physical activity

Correct Answer is ["A","B","C"]

Explanation

A. Relieve client symptoms - Heart failure can cause symptoms like shortness of breath, fatigue, swelling (edema), and difficulty exercising. Relieving these symptoms is an important goal to improve the client's quality of life and overall well-being.

B. Extend survival - Heart failure is a chronic condition that can significantly impact life expectancy. One of the goals of care is to optimize management to extend the client's survival and reduce the risk of complications.

C. Improve functional status - Heart failure can limit a person's ability to perform daily activities and exercise. Improving functional status involves strategies such as medication management, lifestyle modifications, and cardiac rehabilitation to enhance the client's ability to engage in daily activities and maintain independence.

D. Prevent endocarditis - Endocarditis is an infection of the inner lining of the heart chambers and heart valves. While preventing infections is important for overall health, preventing endocarditis may not be directly related to the primary goals of heart failure management. However, maintaining good hygiene and avoiding infections can contribute to the overall well-being of the client.

E. Limit physical activity - This statement is incorrect in the context of heart failure management. Encouraging appropriate levels of physical activity is often part of heart failure care. Physical activity, when tailored to the individual's abilities and guided by healthcare professionals, can improve cardiovascular function, strengthen muscles, and enhance overall health outcomes in clients with heart failure.

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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?

Nursing Test Bank

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