The nurse is caring for a client who is to have an autologous transfusion of packed red blood cells. The nurse recognizes the client requires additional teaching when they state:

“I probably will not have any transfusion reactions from my own blood."

“This is the blood I've been giving for the past 6 weeks for myself.

"I understand there is still a risk I can get hepatitis from this blood."

"Since I have O negative blood, it's a good thing I'm getting my own blood."

Answer and Explanation

The Correct Answer is C

A.   “I probably will not have any transfusion reactions from my own blood.” - Autologous transfusions
generally have a lower risk of transfusion reactions because they involve the client’s own blood.
B.   “This is the blood I’ve been giving for the past 6 weeks for myself.” - This is a correct understanding of the process of autologous blood donation, where the client donates blood for their own use.
C.   An autologous blood transfusion involves the collection and storage of a patient's own blood for later transfusion. This significantly reduces the risk of bloodborne infections, such as hepatitis, HIV, and other blood-borne diseases, as the blood is coming from the patient themselves.
D.   “Since I have O negative blood, it’s a good thing I’m getting my own blood.” - The client may not need additional teaching here because O negative blood is universally compatible, but the reason they are getting their own blood is due to the autologous donation process, not because of blood type.

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Correct Answer is ["11"]

Explanation

The patient weighs 121 lbs, which is approximately 55 kilograms (121 ÷ 2.2).

Next, multiply the patient's weight in kilograms by the dosage prescribed, which is 20 units/kg. This results in a total dosage of 1100 units (55 kg × 20 units/kg).

The medication is supplied as 25,000 units in 250 mL, so to find out how many mL of medication is needed, set up a proportion: 25,000 units is to 250 mL as 1100 units is to X mL. Solving for X gives you 11 mL (1100 units × 250 mL ÷ 25,000 units).

Therefore, the nurse will administer 11 mL of Heparin to the patient.

A. weigh daily on the same scale at the same time of day B. restrict foods that are high in potassium. C. engage in aerobic activity for one hour each day. D. monitor sugar intake

Correct Answer is A

Explanation

A. Weigh daily on the same scale at the same time of day - Daily weight measurement is critical for clients with heart failure to monitor for fluid retention, which can indicate worsening heart failure.
B. Restrict foods that are high in potassium - This is not recommended unless the client is on certain medications (e.g., potassium-sparing diuretics) that cause high potassium levels. Generally, potassium- rich foods are beneficial for heart health.
C. Engage in aerobic activity for one hour each day - Although exercise is important, the intensity and duration should be individualized, and clients with heart failure may need to start with lower-intensity activity.
D. Monitor sugar intake - While important for diabetes management, monitoring sugar intake is not a primary focus for clients with heart failure unless they also have diabetes.

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The nurse is caring for a client who is to have an autologous transfusion of packed red blood cells. The nurse recognizes the client requires additional teaching when they state:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is to receive a bolus of Heparin 20 units/kg. The patient weighs 121 Ibs. The medication is supplied as 25,000 units/250 mL. How many Ml will the nurse give? (round to the nearest whole number)

Correct Answer is ["11"]

Explanation

The nurse is planning care for a client diagnosed with heart failure who will soon be discharged home. What should be included in the teaching plan? The client will:

Correct Answer is A

Explanation

A client presents to the Emergency Department (ED) complaining of a "racing" heart and nervousness. The client also admits to a history of cocaine abuse. The cardiac monitor displays the rhythm below. Which nursing intervention should the nurse perform?

The nurse has provided teaching to a client who had an implantable cardioverter/defibrillator inserted. Which statement by the client indicates the need for further instruction?

The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

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The nurse is assessing the client with a recent pacemaker placement. The client's monitor is displaying what type of rhythm?

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A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 Ibs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)