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 B

Explanation

A. "I will wear layered clothing when walking outside in winter": This statement shows an understanding of the need to dress appropriately for weather conditions, which is important in managing symptoms during physical activity.

B. "I will walk early in the morning when it is hot outside": This statement indicates a lack of understanding regarding the ideal timing for outdoor activities, especially in hot weather. Exercising during the cooler parts of the day (such as early morning or late evening) is recommended to avoid heat-related stress and potential exacerbation of cardiovascular symptoms.

C. "If I get shortness of breath, I should slow down a bit": This statement demonstrates an understanding of monitoring symptoms during exercise and adjusting activity levels accordingly, which is an important aspect of managing coronary artery disease.

D. "My exercise intensity should not exceed my ability to talk": This statement reflects an understanding of the recommended exercise intensity level based on the ability to talk comfortably during physical activity, known as the "talk test."

A. Monitor weight daily B. Assess radial pulses daily C. Monitor bowel movements D. Monitor blood pressure daily

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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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

Naxlex Comprehensive Predictor Exams

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