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.

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Correct Answer is ["A","D","E"]

Explanation

A. Breath sounds
The presence of crackles at the bases of the lungs indicates possible pulmonary congestion or fluid accumulation in the lungs. This could be a sign of pulmonary edema, which may be due to chemotherapy-related side effects such as cardiotoxicity, or other complications like infection (e.g., pneumonia). Given the client's history of chemotherapy, this finding requires follow-up, as it could indicate a serious condition that needs to be addressed promptly.
B. Potassium level
: The client's potassium level is within normal limits (3.5 to 5 mEq/L). Although some chemotherapy drugs may affect electrolyte balance, this potassium level is not concerning at this time.
C. Blood pressure
This blood pressure is within normal limits, as the typical range for adult blood pressure is generally around 120/80 mm Hg. The reading does not indicate hypotension or hypertension, which would be concerning in the context of chemotherapy, which can affect blood pressure.
D. WBC count
A WBC count of 3,800/mm3 is below the normal range of 5,000 to 10,000/mm3, indicating leukopenia or a decreased immune response. This is a common side effect of chemotherapy, which suppresses bone marrow function, leading to lower white blood cell counts. This finding could increase the risk of infection and should be followed up to ensure the patient does not develop an infection, as the lower WBC count could compromise their ability to fight infections.
E. Temperature
A fever of 38.6°C (101.5°F) is significant and suggests the presence of infection, which is especially concerning in a patient with leukopenia due to chemotherapy. A fever in a chemotherapy patient is a medical emergency because of the risk of serious infections like neutropenic fever. This requires immediate follow-up and potentially further diagnostic tests, including blood cultures and a review of the patient's clinical status.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The client is at risk for hypostatic pneumonia as evidenced by the client'simmobility

Rationale

The combination of paraplegia (which leads to limited mobility) and symptoms such as productive cough, tachycardia, and confusion suggest a respiratory issue, likely hypostatic pneumonia.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

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 caring for a client. Exhibits A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A nurse is caring for a client in an acute care setting. Exhibits Complete the following sentence by using the list of options. The client is at risk for dropdownas evidenced by the client's dropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?

Exhibits The nurse is obtaining the client's vital signs prior to an endoscopy. Complete the following sentence by using the list of options. The nurse should first anticipate the need to dropdownthendropdown

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 providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include?

A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray?

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

A nurse is reviewing the medical record of a male client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

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.