nurse is caring for an adult client who has chronic anaemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
Set the IV infusion pump to administer the blood over 6 hr.
Administer the blood via a 21-gauge IV needle.
Check the client's vital signs from the previous shift prior to the initiation of the transfusion
Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
The Correct Answer is D
Choice A reason
Setting the IV infusion pump to administer the blood over 6 hours is not the recommended rate for administering packed RBCs. Blood transfusions are typically given more rapidly, usually within 2 to 4 hours. The specific rate may vary depending on the client's condition and the provider's order.
Choice B reason
Administering the blood via a 21-gauge IV needle is not typically related to the administration of the packed RBCs. The appropriate gauge of the IV needle for blood transfusions depends on the client's condition and the type of transfusion. Larger-gauge needles are often used for blood transfusions to allow for a faster flow rate and prevent haemolysis of the blood cells.
Choice C reason
Checking the client's vital signs from the previous shift prior to the initiation of the transfusion is not sufficient for ensuring the client's safety during the blood transfusion. The nurse should assess the client's current vital signs, including temperature, heart rate, blood pressure, and respiratory rate, before initiating the transfusion. Monitoring vital signs is essential during the transfusion to detect any adverse reactions or changes in the client's condition.
Choice D reason
Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion is the correct answer. When preparing to administer a blood transfusion to an adult client with chronic anaemia, the nurse should rush the blood administration tubing with 0.9% sodium chloride (normal saline) prior to the transfusion. This process is called priming the tubing.
Priming the tubing helps remove any residual air from the tubing and ensures that the blood transfusion is administered smoothly without introducing air into the client's bloodstream. Air embolisms can be a serious complication, and priming the tubing with normal saline helps prevent this risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because varicella, or chickenpox, is a highly contagious disease caused by the varicellazoster virus (VZV), which can spread through the air or by direct contact with the fluid from the blisters. A negative air pressure room prevents the air from the room from circulating to other areas of the hospital, reducing the risk of transmission to other patients and staff.
Choice A is wrong because aspirin should not be given to children with chickenpox, as it can cause a serious condition called Reye’s syndrome, which affects the brain and liver. Instead, acetaminophen can be used to reduce fever.
Choice B is wrong because droplet precautions are not enough to prevent the spread of chickenpox. Droplet precautions involve wearing a mask and gloves when in close contact with the patient, but they do not prevent the virus from traveling through the air. Airborne precautions, which include a negative air pressure room and wearing a respirator, are needed for chickenpox.
Choice D is wrong because Koplik spots are not a sign of chickenpox, but of measles, another viral infection that causes a rash. Chickenpox causes an itchy rash with small, fluid-filled blisters that crust over.
Correct Answer is D
Explanation
the correct answer isd. Your desire to be an organ donor must be documented in writing.This is because organ donation is a legal and medical process that requires your consent and documentation1. Some of the other options are incorrect or misleading. Here are some explanations:
- a.Your namecanbe removed once you are listed on the organ donor list2.You can change your mind at any time and revoke your consent to donate
- b.Youdo nothave to be at least 21 years of age to become an organ donor2.Many states allow people younger than 18 to register as organ donors, but they need parental or guardian consent if they die before their 18th birthday
- c.Youcanhave a witness for your consent to donate, but it is not required1.Some states may require a witness signature on your donor card or registration form, but others do not
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