The nurse is reviewing the client's medical record.
For each potential nursing action, click to specify if the action is indicated or not indicated.
Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above.
Start an IV bolus of lactated Ringer's solution.
Document the blood product transfusion in the client's medical record.
Discard the blood bag in the client's trash can after the transfusion.
Assist with obtaining the first unit of packed RBCs from the blood bank
Monitor the client for the first 15 min of the transfusion.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
- Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
- Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
- Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
- Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.
Not Indicated:
- Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
- Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Prolonged PT/INR. Prolonged PT/INR may occur due to liver dysfunction or vitamin K deficiency, but it is not a direct result of pancreatitis. In pancreatitis, the liver is usually functioning normally unless there is concurrent liver disease.
B. Elevated lipase. Elevated lipase is a hallmark laboratory finding in pancreatitis. Lipase is an enzyme produced by the pancreas, and its levels rise significantly during episodes of pancreatitis, making it a key indicator in diagnosing the condition.
C. Elevated ammonia. Elevated ammonia levels are more commonly associated with liver dysfunction, such as hepatic encephalopathy, rather than pancreatitis. Pancreatitis primarily affects the digestive system, not the liver directly.
D. Decreased albumin. Decreased albumin can be seen in various conditions, including liver disease and malnutrition, but it is not a specific finding for pancreatitis. In acute pancreatitis, albumin levels may not be significantly affected, while chronic pancreatitis can lead to malabsorption and potentially lower albumin levels over time.
Correct Answer is A
Explanation
A. Prepare the client for a chest x-ray to verify catheter placement. A chest x-ray is required after central venous catheter insertion to confirm proper placement before initiating total parenteral nutrition (TPN). Incorrect placement can lead to complications such as pneumothorax, arterial puncture, or catheter malposition, making verification essential for safe administration.
B. Use clean technique when changing the catheter dressing. Central venous catheter dressings require sterile technique, not clean technique, to prevent bloodstream infections. Proper infection control measures, including hand hygiene, chlorhexidine skin antisepsis, and sterile gloves, help minimize the risk of catheter-related bloodstream infections.
C. Verify the amount of TPN solution the client is receiving every 4 hr. TPN is typically monitored continuously, with infusion rates checked at least hourly to ensure proper administration. Regular assessments of fluid balance, glucose levels, and electrolyte status are also necessary to prevent complications such as hyperglycemia or fluid overload.
D. Place the client in Sims' position for catheter insertion. The preferred position for central venous catheter insertion is Trendelenburg or supine, which helps dilate the veins and reduces the risk of air embolism. Sims’ position (lying on the left side with the right knee flexed) is not appropriate for this procedure.
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