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: Foot ulcers and delayed wound healing are related to diabetes but are considered macrovascular complications. Microvascular complications specifically refer to damage to small blood vessels.

Choice B reason: Stroke prevention and cardiac health are important but are related to macrovascular complications of diabetes. The focus here is on microvascular complications.

Choice C reason: Retinopathy and nephropathy are microvascular complications of diabetes. These conditions result from damage to small blood vessels in the eyes and kidneys, respectively. Diabetic retinopathy can lead to vision loss, while diabetic nephropathy can lead to kidney failure. It is important to monitor for these complications and manage blood glucose levels to prevent or slow their progression.

Choice D reason: Hypertension management and cholesterol control are important for overall cardiovascular health but are related to macrovascular complications. The discussion should focus on microvascular complications specific to diabetes.

A. Hypotension B. Bradycardia C. Polyphagia D. Rapid, deep respiration

Correct Answer is A

Explanation

Choice A reason: Hypotension, or low blood pressure, is a common indicator of fluid volume deficit. When a patient is dehydrated or has a significant loss of fluids, their blood volume decreases, leading to lower blood pressure. This condition requires immediate attention and management to prevent complications such as shock or organ failure. Monitoring and correcting fluid balance is crucial in managing patients with diabetic ketoacidosis, making hypotension a significant assessment finding.

Choice B reason: Bradycardia, or slow heart rate, is not typically associated with fluid volume deficit. It is more often related to other conditions such as heart block, hypothyroidism, or use of certain medications. In the context of diabetic ketoacidosis, fluid volume deficit would not manifest primarily as bradycardia.

Choice C reason: Polyphagia, or excessive hunger, is a symptom commonly associated with diabetes mellitus but does not indicate fluid volume deficit. Polyphagia results from the body's inability to use glucose properly, leading to increased hunger. It is not directly related to the patient's hydration status or fluid volume.

Choice D reason: Rapid, deep respiration, also known as Kussmaul breathing, is a compensatory mechanism in response to metabolic acidosis, a hallmark of diabetic ketoacidosis. While it is an important clinical sign, it does not specifically indicate fluid volume deficit. Kussmaul respiration occurs due to the body's attempt to expel excess carbon dioxide and correct the acid-base imbalance.

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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

The nurse is discussing microvascular complications of diabetes with a patient. What topics will the nurse include in the discussion?

Correct Answer is C

Explanation

The nurse is caring for a patient with diabetic ketoacidosis. Which assessment finding indicates to the nurse that the patient is experiencing fluid volume deficit?

Correct Answer is A

Explanation

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