The nurse is preparing to start a transfusion of packed red blood cells for a client with a hemoglobin of 5.4 g/dL. (normal Female: 11.7-15.5 g/dL; Male: 14-17.3 g/dL). Which IV site should the nurse use?
20-gauge catheter in the right wrist infusing IV antibiotics
18-gauge catheter infusing 20 mEq Potassium Chloride IV
22-gauge catheter in the left forearm infusing 0.9% Normal Saline
20-gauge catheter in the right forearm infusing 0.9% Normal Saline
The Correct Answer is D
A. The 20-gauge catheter in the right wrist is not ideal for blood transfusions, as wrist veins are smaller and may be less optimal for high-flow transfusions.
B. An 18-gauge catheter is appropriate for blood transfusions, but the catheter is currently in use for potassium chloride, which would need to be discontinued. The best choice is a separate site.
C. A 22-gauge catheter is not large enough for blood transfusion; it may cause hemolysis or slow the transfusion rate.
D. The 20-gauge catheter in the right forearm is an appropriate size for a blood transfusion and is currently infusing normal saline, which does not interfere with the blood transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. These are not typical symptoms of atrial flutter. They may be seen in other conditions like hypertensive crisis or systemic problems, but not as a primary manifestation of atrial flutter.
B. These are classic signs of diabetes or hyperglycemia, not atrial flutter.
C. These are common symptoms of atrial flutter, which results in an irregular heart rhythm and may cause increased heart rate, leading to palpitations and shortness of breath.
D. A systolic murmur is more associated with valve problems, and anxiety could be a result of various issues but is not a typical finding directly caused by atrial flutter.
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