The nurse is monitoring a patient who is receiving a blood transfusion. The nurse identifies that the blood transfusion started over four hours ago. What intervention will the nurse implement next?

Increase the rate of the transfusion to complete it as quickly as possible.

Stop the transfusion immediately and document the amount infused.

Continue the transfusion and monitor vital signs every 15 minutes.

Continue the transfusion at the current rate until it is completed.

Answer and Explanation

The Correct Answer is B

Choice A reason: Increasing the rate of the transfusion to complete it as quickly as possible is not safe. Blood transfusions should be completed within four hours to prevent complications such as bacterial contamination and hemolysis.

Choice B reason: Stopping the transfusion immediately and documenting the amount infused is the appropriate intervention. Blood products that have been transfusing for more than four hours must be stopped to ensure patient safety and prevent adverse reactions. Documentation ensures that the healthcare team is aware of the situation and can take appropriate follow-up actions.

Choice C reason: Continuing the transfusion and monitoring vital signs every 15 minutes is not appropriate after the four-hour window has passed. The risk of complications increases with prolonged transfusion times.

Choice D reason: Continuing the transfusion at the current rate until it is completed is not safe. The transfusion must be stopped after four hours to prevent potential complications.

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Correct Answer is C

Explanation

Choice A reason: Encouraging the patient to rest in bed for most of the day may lead to further deconditioning and muscle weakness. While rest is important, balancing activity and rest is more beneficial for managing fatigue in chronic anemia.

Choice B reason: Administering a high-protein diet including caffeinated beverages to increase energy levels is not recommended. While a high-protein diet can support energy and muscle strength, caffeine may cause jitteriness and disrupt sleep, which can exacerbate fatigue.

Choice C reason: Assisting the patient with ADLs and encouraging frequent rest periods is appropriate for managing fatigue, weakness, and activity intolerance in chronic anemia. This approach helps the patient conserve energy while maintaining some level of activity to prevent deconditioning.

Choice D reason: Providing supplemental oxygen via face mask during vigorous exercises is not appropriate. Patients with chronic anemia should avoid vigorous exercises that could exacerbate fatigue and weakness. The focus should be on moderate, manageable activities with adequate rest.

A. pH 7.30, PaCO2 59, HCO3 30 B. pH 7.50, PaCO2 30, HCO3 24 C. pH 7.48, PaCO2 42, HCO3 29 D. pH 7.33, PaCO2 34, HCO3 18

Correct Answer is A

Explanation

Choice A reason: The lab results pH 7.30, PaCO2 59, HCO3 30 indicate respiratory acidosis with partial compensation. This is a typical finding in patients with chronic obstructive pulmonary disease (COPD) due to chronic hypoventilation and CO2 retention. The elevated PaCO2 reflects respiratory acidosis, and the elevated HCO3 indicates renal compensation to maintain acid-base balance.

Choice B reason: The lab results pH 7.50, PaCO2 30, HCO3 24 indicate respiratory alkalosis. This is not typical for COPD, where respiratory acidosis is more common.

Choice C reason: The lab results pH 7.48, PaCO2 42, HCO3 29 indicate metabolic alkalosis with partial compensation, which is not consistent with the primary respiratory issues seen in COPD.

Choice D reason: The lab results pH 7.33, PaCO2 34, HCO3 18 indicate metabolic acidosis with partial compensation, which is not typical for COPD. COPD primarily causes respiratory acidosis due to CO2 retention.

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The nurse is monitoring a patient who is receiving a blood transfusion. The nurse identifies that the blood transfusion started over four hours ago. What intervention will the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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