Order the steps for completing a blood transfusion.
Ensure MDHCP has discussed risks and benefits of blood transfusion.
Obtain cross match and send it to blood bank.
Initiate transfusion through a large gauge IV per hospital protocol.
Educate patient on signs and symptoms of transfusion reaction.
Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs.
Continue to monitor patient for transfusion reaction for 24 hours following transfusion.
The Correct Answer is A,D,B,E,C,F,G,H,I
- Ensure MDHCP has discussed risks and benefits of blood transfusion. (a)
- Educate patient on signs and symptoms of transfusion reaction. (d)
- Obtain cross match and send it to blood bank. (b)
- Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs. (e)
- Initiate transfusion through a large gauge IV per hospital protocol. (c)
- Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes. (f)
- Increase rate of transfusion and monitor patient frequently. (g)
- Ensure transfusion is complete within 4 hours of starting. (h)
- Continue to monitor patient for transfusion reaction for 24 hours following transfusion. (i)
Rationale:
- Ensure MDHCP has discussed risks and benefits of blood transfusion: It's essential that the healthcare provider discusses with the patient the potential risks and benefits of receiving a blood transfusion. This step is crucial for informed consent.
- Educate patient on signs and symptoms of transfusion reaction: Before starting the transfusion, the patient should be educated on what signs and symptoms to watch out for that might indicate an adverse reaction, such as fever, chills, hives, or shortness of breath.
- Obtain cross match and send it to blood bank: A blood sample is taken from the patient to determine their blood type and to perform a crossmatch, which ensures that the donor blood is compatible with the patient's blood.
- Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs: Once the blood is ready, two registered nurses (RNs) will verify the patient's identity, the blood product, and the crossmatch results to ensure everything is correct before proceeding.
- Initiate transfusion through a large gauge IV per hospital protocol: The blood transfusion is started using a large gauge intravenous (IV) line, as per hospital protocols to ensure proper flow and reduce complications.
- Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes: The transfusion is started at a slow rate to monitor for any immediate adverse reactions. The healthcare provider stays with the patient during this time to closely observe them.
- Increase rate of transfusion and monitor patient frequently: If no adverse reactions are noted in the first 15 minutes, the rate of transfusion can be increased. The patient is monitored frequently throughout the transfusion for any signs of a reaction.
- Ensure transfusion is complete within 4 hours of starting: Blood products should be transfused within 4 hours to minimize the risk of bacterial growth and to ensure the effectiveness of the transfusion.
- Continue to monitor patient for transfusion reaction for 24 hours following transfusion: After the transfusion is complete, the patient is monitored for at least 24 hours for any delayed transfusion reactions, such as fever, allergic reactions, or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F","G"]
Explanation
Choice A reason: Weight loss is indicative of hypermetabolism caused by excessive thyroid hormone production. The increased metabolic rate leads to higher energy consumption, resulting in unintentional weight loss even if the patient maintains or increases their food intake.
Choice B reason: Begins to cry when he tells you he recently lost his wife. Emotional responses, such as crying, can be associated with personal loss and grief but are not directly linked to hypermetabolism or excess thyroid hormone. This statement reflects the patient's emotional state rather than a physiological manifestation of hyperthyroidism.
Choice C reason: Hyperactive bowel sounds are a common manifestation of hypermetabolism due to hyperthyroidism. The increased metabolic rate accelerates gastrointestinal motility, resulting in hyperactive bowel sounds and sometimes diarrhea.
Choice D reason: 1+ pitting edema noted in bilateral lower extremities is related to fluid retention and heart failure rather than hypermetabolism. Edema is not a typical manifestation of hyperthyroidism and is more indicative of cardiovascular or renal issues.
Choice E reason: A heart rate of 124 (tachycardia) is a common finding in patients with hyperthyroidism. Excess thyroid hormones increase the heart rate and cardiac output, leading to symptoms such as palpitations and tachycardia.
Choice F reason: Bounding radial pulses are indicative of increased cardiac output and stroke volume, which are common in hyperthyroidism due to the hypermetabolic state induced by excess thyroid hormones. This leads to strong and forceful pulses.
Choice G reason: Anxious and restless behavior is a manifestation of the increased adrenergic activity associated with hyperthyroidism. Excess thyroid hormones stimulate the nervous system, leading to symptoms such as anxiety, restlessness, and irritability.
Correct Answer is C
Explanation
Choice A reason: Suggesting the use of adult incontinence briefs for nighttime only may help manage incontinence during the night, but it does not address the primary issue of urinary retention caused by a flaccid bladder. Incontinence briefs are a passive approach and do not prevent urinary retention or the complications associated with it, such as urinary tract infections and kidney damage. Additionally, it does not empower the patient to actively manage their urinary retention.
Choice B reason: Assisting the patient to the commode every 2 hours during the day can help to some extent in managing urinary retention. However, this approach requires constant assistance and is not practical for long-term management, especially when the patient is alone or in settings where frequent assistance is not available. This method also does not ensure complete bladder emptying, which is crucial for preventing urinary tract infections and other complications.
Choice C reason: Teaching the patient how to self-catheterize is the most appropriate and effective action for managing urinary retention caused by a flaccid bladder. Self-catheterization allows the patient to empty the bladder regularly and completely, reducing the risk of urinary tract infections, bladder distention, and kidney damage. It also provides the patient with a sense of control and independence in managing their condition. Self-catheterization is a standard and recommended practice for individuals with neurogenic bladder dysfunction due to multiple sclerosis.
Choice D reason: Encouraging decreased evening intake of fluid can help reduce nighttime urination, but it does not address the issue of urinary retention caused by a flaccid bladder. Decreasing fluid intake is not a comprehensive solution and does not prevent complications associated with incomplete bladder emptying. It is important to manage fluid intake appropriately, but this should be part of a broader strategy that includes effective bladder emptying techniques like self-catheterization.
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