The nurse reviews the entries in the medical record
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.
Start an IV bolus of lactated Ringers solution.
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg 4
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Rationale:
• Stay with the client for the first 15 min of the transfusion: The first 15 minutes of a blood transfusion are critical for monitoring signs of a transfusion reaction, such as fever, chills, rash, or hypotension. Continuous observation allows the nurse to promptly intervene and prevent complications.
• Obtain the first unit of packed RBCs from the blood bank: Retrieving the blood from the blood bank ensures that the correct product is available for transfusion and meets safety protocols. Verification of type and crossmatch is essential before administration.
• Document the blood product transfusion in the client's medical record: Accurate documentation of the transfusion, including product type, volume, time, and client response, is required for legal, medical, and safety purposes. It ensures continuity of care and provides a record for any adverse events.
• Start an IV bolus of lactated Ringers solution: Routine IV bolus of lactated Ringer’s is not indicated unless the client has persistent hypotension requiring fluid resuscitation. Blood transfusion itself is the primary intervention to correct anemia in this client.
• Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: While monitoring blood pressure is important, adjusting the transfusion rate specifically to maintain a numeric BP is not standard practice. The transfusion rate should follow protocol, usually starting slow for the first 15 minutes and then adjusted per tolerance, not solely based on BP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Allow extra time for the client to perform tasks: Clients with vision loss may need additional time to orient themselves, perform activities of daily living, and navigate safely. Allowing extra time supports independence and reduces the risk of injury or frustration.
B. Touch the client gently to announce presence: Gently touching the client on the arm or shoulder before speaking helps prevent startling them and provides a clear cue that someone is nearby. This enhances safety and effective communication for clients with impaired vision.
C. Keep objects in the client's room in the same place: Consistently organizing personal items and equipment in fixed locations helps clients with vision loss locate items safely and reduces the risk of tripping or injury. This is an essential component of creating a safe environment.
D. Ensure there is high-wattage lighting in the client's room: Excessive or harsh lighting can cause glare, which may worsen visual difficulties for clients with certain types of vision loss. Appropriate lighting should be sufficient but not overly bright, emphasizing contrast rather than intensity.
E. Approach the client from the side: Approaching from the side may startle a client with vision loss. It is safer and more effective to approach from the front while identifying oneself to maintain clear communication and orientation.
Correct Answer is D
Explanation
Rationale:
A. Place the client in supine position: The supine position is not ideal for paracentesis. The procedure is typically performed with the client sitting upright on the edge of the bed or in a high Fowler’s position, allowing fluid to collect in the lower abdomen and reducing the risk of organ puncture.
B. Ensure the client has a full bladder: A full bladder increases the risk of bladder puncture during paracentesis. Clients are usually asked to void before the procedure to minimize this risk and promote safety.
C. Obtain a creatinine level: While kidney function may be relevant to overall health, measuring creatinine is not required specifically for paracentesis. The procedure focuses on removing ascitic fluid and assessing for infection or other complications, not directly on renal function.
D. Weigh the client: Weighing the client before the procedure establishes a baseline to evaluate the amount of fluid removed and monitor changes in fluid status. Pre- and post-procedure weights help assess effectiveness and detect complications such as hypotension or fluid shifts.
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