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NurseDive Free Nursing Practice Question
A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take?
A. Administer each unit over 3 hr.
Administering packed red blood cells (PRBCs) over a specific timeframe is a crucial aspect of transfusion therapy. While the ideal duration for administering 1 unit of PRBCs is typically 2-4 hours, the specific rate depends on the client's condition, healthcare provider's orders, and institutional protocols. In certain situations, especially for older adult clients who may be more sensitive to rapid transfusions, administering each unit over a longer period (such as 3 hours) can help reduce the risk of adverse reactions, such as transfusion-related lung injury (TRALI) or fluid overload. Slower transfusion rates are often recommended for clients at higher risk of complications.
B. Use an 18-gauge needle to obtain venous access.
The gauge of the needle used for venous access during PRBC transfusions is an important consideration. However, using an 18-gauge needle, which is larger in diameter, may not be necessary for most clients and can cause discomfort or vein damage, particularly in older adults with fragile veins. A smaller gauge needle, such as 20-22 gauge, is usually sufficient for venous access and reduces the risk of complications such as infiltration or phlebitis.
C. Obtain the client's vital signs every 30 min throughout the transfusion.
Monitoring the client's vital signs, including temperature, blood pressure, pulse rate, and respiratory rate, at regular intervals during the transfusion is a standard and essential practice. This allows for early detection of transfusion reactions, hemolytic reactions, or other complications that may arise during the transfusion process. Monitoring every 30 minutes is a guideline commonly followed to ensure client safety.
D. Use blood that is less than a month old.
The age of blood used for transfusions is a critical factor in maintaining its efficacy and reducing the risk of adverse reactions. Fresh blood (less than a month old) is preferable, but the acceptable age of blood can vary depending on institutional policies and guidelines. While using fresher blood is ideal, blood that is up to 42 days old is generally considered acceptable for transfusion in many healthcare settings.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med surg exam 1A Proctored Exam. Take the full exam now
Similar Questions
A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?
A. Decreased urine specific gravity
In fluid volume deficit, urine becomes more concentrated due to decreased kidney perfusion and water conservation by the body. This results in an increased urine specific gravity.
B. Decreased Hgb
Fluid volume deficit typically leads to hemoconcentration because there is less plasma volume, which makes hemoglobin and hematocrit levels appear elevated.
C. Increased urine ketones
While increased urine ketones may occur in dehydration associated with starvation or diabetic ketoacidosis (DKA), it is not a hallmark finding in general fluid volume deficit. The presence of ketones depends on the underlying cause, not on fluid volume status alone.
D. Increased BUN
Blood urea nitrogen (BUN) increases in fluid volume deficit because of hemoconcentration and reduced kidney perfusion, which slows the excretion of urea. The ratio of BUN to creatinine is often elevated in dehydration (>20:1).
Full Explanation
A. Decreased urine specific gravity: In fluid volume deficit, urine becomes more concentrated due to decreased kidney perfusion and water conservation by the body. This results in an increased urine specific gravity.
B. Decreased Hgb: Fluid volume deficit typically leads to hemoconcentration because there is less plasma volume, which makes hemoglobin and hematocrit levels appear elevated.
C. Increased urine ketones: While increased urine ketones may occur in dehydration associated with starvation or diabetic ketoacidosis (DKA), it is not a hallmark finding in general fluid volume deficit. The presence of ketones depends on the underlying cause, not on fluid volume status alone.
D. Increased BUN: Blood urea nitrogen (BUN) increases in fluid volume deficit because of hemoconcentration and reduced kidney perfusion, which slows the excretion of urea. The ratio of BUN to creatinine is often elevated in dehydration (>20:1).
A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings?
A. Urine specific gravity 1.035
Fluid volume deficit leads to decreased fluid intake or excessive fluid loss, which results in concentrated urine. A urine specific gravity of 1.035 indicates highly concentrated urine, suggesting the kidneys are conserving water in response to decreased fluid volume. Sodium (Na+) level of 155 mEq/L is not a specific finding related to fluid volume deficit. Sodium levels can be influenced by various factors, including dietary intake and renal function, but it is not a direct consequence of hypovolemia. BUN (blood urea nitrogen) level of 19 mg/dL falls within the normal range and is not specific to fluid volume deficit. BUN levels can be influenced by factors such as protein intake, liver function, and renal function. Hematocrit (Hct) level of 44% represents the percentage of red blood cells in the total blood volume. While fluid volume deficit can cause hemoconcentration, the Hct level alone may not provide a definitive indication of fluid volume status.
B. Sodium 155 mEq/L
C. BUN 19 mg/dL
D. Hematocrit 44%
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. 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)
Full Explanation
The infusion rate for 0.45% NaCl 1000 mL over 8 hours is calculated as follows:
1000 mL / 8 hr = 125 mL/hr