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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Viral load count is the primary test used to assess the effectiveness of HIV therapy by measuring the amount of HIV RNA in the blood, indicating how well the treatment is controlling the virus.
B. The Western blot is used as a confirmatory test for HIV diagnosis rather than monitoring therapy effectiveness.
C. The Enzyme immunoassay (EIA) test is used for initial HIV screening but does not measure viral load or therapy effectiveness.
D. Platelet count can be affected in HIV infection, especially with advanced disease, but it does not directly measure the effectiveness of HIV therapy.
Correct Answer is C
Explanation
A. Dietary iron restrictions may affect iron intake, but they are not a direct symptom of ulcerative colitis that contributes to anemia.
B. Intestinal parasites can cause anemia but are not a common complication associated with ulcerative colitis.
C. Chronic bloody diarrhea is a significant symptom of ulcerative colitis and leads to iron loss and depletion, contributing to the development of anemia due to the loss of blood and iron.
D. Intestinal malabsorption syndrome can lead to anemia; however, it is not a primary symptom of ulcerative colitis itself, making chronic bloody diarrhea the more direct contributing factor.
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