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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. is expected to be decreased for three to five days.
In the initial stages following severe burn injury, there is often oliguria (low urine output), but this is typically followed by diuresis (increased urine output) after the first 24-48 hours, not a decrease over 3-5 days.
B. will be reduced in the first 24-48 hours and will then increase.
In the first 24-48 hours following a severe burn injury, the body may undergo a state of hypovolemia and oliguria. As fluid resuscitation begins, urine output typically increases.
C. output will be greatest in the first 24 hours after the burn injury.
Although urine output may increase with proper fluid resuscitation, it is not usually greatest in the first 24 hours; the increase typically happens after the initial resuscitation period.
D. will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
While fluid resuscitation leads to an increase in urine output after the first 24-48 hours, it is not expected to be elevated right away. The kidneys may initially respond with oliguria.
Correct Answer is B
Explanation
A. Hydrocodone and acetaminophen 5/500 mg PO
Opioids are generally ineffective for neuropathic pain, and trigeminal neuralgia is best managed with anticonvulsants.
B. Carbamazepine 200 mg PO
Carbamazepine (an anticonvulsant) is the first-line treatment for trigeminal neuralgia. It helps reduce nerve excitability and pain episodes.
C. Methotrexate 5 mg PO
Methotrexate is an immunosuppressant and chemotherapy drug, not used for trigeminal neuralgia.
D. Linezolid 600 mg PO
Linezolid is an antibiotic used for bacterial infections, not neuropathic pain.
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