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. Heart rate 98/min. A heart rate of 98 beats per minute is within the normal range for adults, which is typically between 60 and 100 beats per minute. Therefore, this finding does not require reporting.
B. Temperature 38.0 °C (100.4 °F). A temperature of 38.0 °C (100.4 °F) is considered a low-grade fever and may indicate an infection or other underlying condition. This finding should be reported to the charge nurse for further assessment and potential intervention.
C. Respiratory rate 14/min. A respiratory rate of 14 breaths per minute is within the normal range for adults, which is generally between 12 and 20 breaths per minute. This finding does not require reporting.
D. Blood pressure 142/88 mm Hg. A blood pressure reading of 142/88 mm Hg is classified as elevated or stage 1 hypertension. While it is important to monitor blood pressure, this finding may not require immediate reporting unless there are additional concerning symptoms or a significant change from the client's baseline readings.
Correct Answer is ["A","B","D","E"]
Explanation
A. Alternate activity and rest. Clients with heart failure should balance activity and rest to prevent overexertion and minimize cardiac workload. Frequent rest periods help conserve energy and reduce symptoms such as dyspnea and fatigue.
B. Reduce sodium intake to 2 g per day. Limiting sodium intake helps prevent fluid retention and reduces the risk of worsening heart failure. Excess sodium contributes to increased blood volume and exacerbates symptoms such as edema and shortness of breath.
C. Consume a low-fiber diet. A low-fiber diet is not necessary for heart failure management. Adequate fiber intake is beneficial for preventing constipation, which can increase strain during bowel movements and lead to hemodynamic stress. A high-fiber diet is generally encouraged.
D. Gradually increase activity each day. Clients should slowly increase their activity level based on tolerance to improve cardiovascular function. Overexertion should be avoided, but regular, controlled exercise helps maintain mobility and enhance overall heart health.
E. Eat small, frequent meals each day. Eating smaller meals reduces gastric distension and minimizes pressure on the diaphragm, which can help alleviate shortness of breath. Large meals can increase metabolic demands and contribute to discomfort in clients with heart failure.
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