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.

Stay with the client for the first 15 min of the transfusion.

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

Obtain the first unit of packed RBCs from the blood bank.

Start an IV bolus of lactated Ringer's solution.

Document the blood product transfusion in the client's medical record.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Rationale
1. Stay with the client for the first 15 minutes of the transfusion.

Indicated
This is a standard protocol for blood transfusions. The first 15 minutes of the transfusion are the most critical because acute transfusion reactions (such as allergic reactions, febrile reactions, or hemolysis) are most likely to occur during this time. By staying with the client, the nurse can monitor for any signs of reaction (e.g., fever, chills, shortness of breath, rash) and intervene immediately if necessary.

2. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

Indicated
Given the client’s low blood pressure (hypotension), it is important to monitor and potentially titrate the rate of infusion during the blood transfusion. The nurse should ensure that the blood pressure is maintained at an acceptable level. Blood transfusions can cause fluid shifts and affect hemodynamics, so the nurse may adjust the transfusion rate based on the client's vital signs to maintain adequate blood pressure and avoid complications, such as fluid overload or inadequate tissue perfusion.
3. Obtain the first unit of packed RBCs from the blood bank.

Indicated
The client is being prepared for a blood transfusion, so obtaining the blood product from the blood bank is a necessary step. The nurse must ensure that the correct blood product (two units of packed RBCs) is ordered, cross-matched, and ready for administration. Blood verification is critical to avoid transfusion errors, and this step is essential for the transfusion process.
4. Start an IV bolus of lactated Ringer's solution.
The provider’s prescription specifies a 500 mL bolus of normal saline (0.9% sodium chloride), not lactated Ringer's solution. Normal saline is preferred for blood transfusions because it does not contain calcium, which can bind to the citrate in blood products and cause clotting or other complications. Using the correct IV solution is essential for safety.
5. Document the blood product transfusion in the client's medical record.

Indicated
Proper documentation is essential in nursing practice. The nurse must record key information regarding the blood transfusion, including the type of blood product, the date and time of transfusion, the rate of infusion, and any reactions or complications. Documentation helps ensure continuity of care, and it is required by legal and institutional standards.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. While securing the tracheostomy tube is important, the focus should be on the dressing care and maintaining airway patency rather than tie adjustments.
B. Changing the dressing using clean technique is critical to prevent infection and should be part of the discharge instructions.
C. Operating the suction machine is an important skill, but it may not be needed daily unless suctioning is required.
D. Non-disposable tracheostomy tubes should not be changed daily unless specified by the provider.

A. Place a towel roll under the client's neck. B. Align a trochanter wedge between the client's legs. C. Position a pillow under the client's knees. D. Apply an orthotic to the client's foot.

Correct Answer is D

Explanation

A. A towel roll under the neck is not effective for preventing contractures, which most commonly affect the arms and legs.
B. A trochanter wedge helps to maintain proper alignment of the hips but does not address contractures in the limbs.
C. A pillow under the knees can lead to contractures in the legs. It is more effective to keep the legs straight with proper positioning.
D. An orthotic to the foot can help prevent foot drop and other contractures in the lower extremities by maintaining the proper position.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?

Correct Answer is D

Explanation

A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?

A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching?

A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client?

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?

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.