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Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

Hang a bag of 0.9% normal saline with 5% dextrose at the bedside (D5%NS)

Verify the client's name and blood type with a second nurse

Infuse the unit of blood within 4 hours.

Obtain baseline vital signs prior to starting the transfusion

Continuously monitor the client during the first 15 minutes of the transfusion

Insert an 18-gauge intravenous catheter

Insert a 22-gauge intravenous catheter

Answer and Explanation

Correct Answer : B,C,D,E,F

A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.

B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.

C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.

D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.

E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.

F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.

G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.

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Correct Answer is B

Explanation

A. Fungal and bacterial infections can occur later as the immune system becomes compromised, but they are not initial symptoms of HIV infection.

B. Flu-like symptoms and night sweats are common initial manifestations of acute HIV infection, often occurring within 2-4 weeks after exposure.

C. Kaposi's sarcoma is a type of cancer associated with advanced HIV/AIDS and not an initial symptom of infection.

D. Pneumocystis lung infection typically occurs later in the course of HIV disease when the immune system is severely weakened, not during the initial infection stage.

Correct Answer is ["117"]

Explanation

Infusion rate (mL/hr) = Volume to be infused (mL) / Time (hr)

In this case:

Volume to be infused = 350 mL
Time = 3 hours

Plugging the values into the formula:

Infusion rate = 350 mL / 3 hours = 116.67 mL/hr

Rounding to the nearest whole number, the infusion rate is 117 mL/hr.

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Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which manifestation(s) should the nurse include?

Correct Answer is B

Explanation

A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["117"]

Explanation

A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

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The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select three options that apply.

A nurse is caring for a client who is coming to the clinic for human immunodeficiency virus (HIV) testing. The patient's enzyme-linked immunosorbent assay (ELISA) results are positive. Which test will be used to confirm the diagnosis of HIV?

Select the appropriate treatment for the following transfusion reactions

Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply