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 D
Explanation
Rationale:
A. Forearm: The forearm is generally used for intradermal injections, such as tuberculin or allergy testing, rather than subcutaneous injections. It has limited subcutaneous tissue and is not ideal for medications requiring slower absorption.
B. Vastus lateralis: The vastus lateralis is a preferred site for intramuscular injections, particularly in infants and young children, due to its large muscle mass. It is not the first choice for subcutaneous injections because absorption dynamics differ.
C. Ventrogluteal: The ventrogluteal site is a preferred intramuscular injection site in adults and children but is not commonly used for subcutaneous injections. Its depth and tissue composition make it less suitable for subcutaneous administration.
D. Abdomen: The abdomen is a recommended site for subcutaneous injections because it has a layer of subcutaneous fat that allows for consistent absorption. Areas at least 2 inches away from the umbilicus are preferred to avoid irritation and ensure proper medication delivery.
Correct Answer is A
Explanation
Rationale:
A. "Use an electric razor when shaving while taking this medication.": Warfarin is an anticoagulant that increases the risk of bleeding. Using an electric razor reduces the risk of cuts and subsequent bleeding, which is an important safety measure for clients on warfarin therapy.
B. "Take a dose of the medication every 5 minutes for a maximum of three doses": This instruction is inappropriate and unrelated to warfarin. Warfarin is taken orally once daily, and frequent dosing in short intervals could lead to serious bleeding complications.
C. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption or activity. The client should be cautioned about foods high in vitamin K, such as leafy greens, because they can interfere with warfarin’s anticoagulant effect.
D. "This medication can cause hearing loss.": Hearing loss is not a known adverse effect of warfarin. The primary concerns are bleeding risks, bruising, and interactions with other medications or foods.
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