The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client?
(Select All that Apply)

Administer each unit of blood over 34 hour

Anticipate an order for acetaminophen

Anticipate an order for furosemide administration

Assess for signs and symptoms of fluid overload

Anticipate administration of FFP for the next transfusion

Answer and Explanation

Correct Answer : A,C,D

A. Administer each unit of blood over 3–4 hours

Older clients with CHF cannot tolerate rapid fluid shifts. Blood should be administered slowly (over 3–4 hours per unit) to prevent fluid overload.

B. Anticipate an order for acetaminophen

Acetaminophen is not routinely given before blood transfusions unless the client has a history of febrile reactions.

C. Anticipate an order for furosemide administration

Loop diuretics like furosemide may be ordered between units to prevent fluid overload in CHF patients.

D. Assess for signs and symptoms of fluid overload

CHF patients are at high risk for fluid overload, leading to dyspnea, crackles, and increased BP.

E. Anticipate administration of fresh frozen plasma (FFP) for the next transfusion

FFP is given for coagulation disorders, not for treating anemia in a GI bleed.

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Correct Answer is C

Explanation

A. Respiratory rate 24 and bloody drainage in the NG tube

While an increased respiratory rate and bloody drainage are concerning, they may not indicate an immediate life-threatening situation compared to the other options.

B. Client is oriented to name and place but not the date

This suggests some level of confusion or altered mental status, which is important but not necessarily an immediate threat.

C. Blood pressure 40/48 and urine output of 24 mL/hour

This indicates severe hypotension and inadequate perfusion, which are signs of ongoing shock and possibly continued internal bleeding. Immediate intervention is critical.

D. Hypo-active bowel sounds and tachycardia

Hypo-active bowel sounds and tachycardia are concerning and suggestive of shock, but they are not as immediately life-threatening as severely low blood pressure and low urine output.

A. inability to understand directions B. Lesion of cranial nerve IX C. Dysfunction of the cerebellum D. Vestibular disease

Correct Answer is C

Explanation

A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.

B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.

C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.

D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.

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The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client? (Select All that Apply)

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client?
(Select All that Apply)