The nurse reviews the entries in the medical record.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
Start an IV bolus of lactated Ringer's solution.
Stay with the client for the first 15 min of the transfusion.
Obtain the first unit of packed RBCs from the blood bank.
Document the blood product transfusion in the client's medical record.
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Indicated:
Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mmHg: - The client is hypotensive (76/45 mmHg), likely due to acute blood loss anemia from a gastrointestinal (GI) bleed. Adjusting the transfusion rate helps stabilize BP while preventing volume overload.
Stay with the client for the first 15 minutes of the transfusion: The highest risk of a transfusion reaction (e.g., hemolysis, anaphylaxis, febrile reaction) occurs within the first 15 minutes, so the nurse must remain with the client for close monitoring.
Obtain the first unit of packed RBCs from the blood bank: The client’s condition (hypotension, tachycardia, history of melena) suggests GI bleeding and significant blood loss. RBC transfusion is required to restore oxygen-carrying capacity and improve perfusion.
Document the blood product transfusion in the client’s medical records: Proper documentation includes blood product type, volume infused, time started and completed, client response, and any adverse reactions. This ensures compliance with safety protocols.
Not Indicated:
Start an IV bolus of lactated Ringer’s solution: Lactated Ringer’s (LR) is incompatible with blood products because it contains calcium, which can cause clotting in the IV line. Normal saline (0.9% NaCl) should be used instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Encouraging a focus on tertiary health interventions might not address the preventive health needs of the population.
B. Incorrect. While raising awareness about industrial pollution is important, it might not be the primary focus of a public health program in a rural area.
C. Incorrect. Utilizing a nurse from outside the community might not be the most effective approach for understanding the specific health needs and context of the local population.
D. Correct. Providing anticipatory guidance classes to parents through public schools is a community-based preventive approach that can address the health needs of families and children in the area.
Correct Answer is D
Explanation
A. A client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.
- A client who received a pain medication 30 min ago for postoperative pain may not need immediate assessment, unless there are signs of increased pain or other complications. The nurse can document the medication administration and observe the client’s response.
- A client who has 100 mL of fluid remaining in his IV bag may not need immediate assessment, unless there are signs of fluid overload or electrolyte imbalance. The nurse can monitor the client’s fluid intake and output, weight, blood pressure, pulse, temperature, and laboratory values.
- A client who was just given a glass of orange juice for a low blood glucose level need immediate assessment to reassess for persistent hypoglycemia
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