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A client with bladder cancer has lost an estimated 500 mL blood in the urine. The client's hemoglobin is 8.0 g/dL, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should:
- A. Attach the packed cells to the existing 19G I.V. of normal saline solution using Y tubing.
- B. Start an additional 22G I.V. site because the packed blood cells must be given in a separate line.
- C. Attach the packed blood cells to the existing 22G I.V. of 5% dextrose using Y tubing.
- D. Start an additional I.V. access device with a 22G Intracath.
Correct Answer: A
Rationale: Packed red blood cells should be administered via a 19G I.V. with normal saline using Y tubing to prevent hemolysis, which can occur with dextrose solutions.
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The nurse is teaching a client who is scheduled for a transfusion of one unit of packed red blood cells (PRBCs). Which of the following information should the nurse include?
- A. A baseline weight will be taken before the start of the transfusion.
- B. I will be with you during the transfusion's first fifteen minutes.
- C. You will need to provide a urine sample at the end of the transfusion.
- D. Please complete the required surgical consent before the transfusion.
Correct Answer: B
Rationale: The nurse must stay with the client during the first 15 minutes of a PRBC transfusion to monitor for acute reactions, which are most likely to occur early. Baseline weight is relevant for fluid overload risk, not routine. Urine samples are not standard, and surgical consent is not required for transfusions.
When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
- A. Verify patency of the line by the presence of a blood return at regular intervals.
- B. Inspect the insertion site for swelling, erythema, or drainage.
- C. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
- D. If unable to aspirate blood, reposition the client and encourage the client to cough.
- E. Contact the health care provider about verifying placement if the status is questionable.
Correct Answer: A,B,D,E
Rationale: Verifying patency (A), inspecting the site (B), repositioning for no blood return (D), and contacting the provider if placement is questionable (E) are critical to ensure safe chemotherapy administration. Administering without blood return (C) risks extravasation and tissue damage.
A physician orders a lengthy X-ray examination for a client with osteoarthritis. Which of the following actions by the nurse would demonstrate client advocacy?
- A. Contact the X-ray department and ask the technician if the lengthy session can be divided into shorter sessions.
- B. Contact the physician to determine if an alternative examination could be scheduled.
- C. Provide a dose of acetaminophen (Tylenol).
- D. Cancel the examination because of the hard X-ray table.
Correct Answer: A
Rationale: Dividing the session into shorter ones reduces discomfort, advocating for the client's comfort while ensuring the test is completed.
The nurse is planning care for a client with a history of peripheral vascular disease who has symptoms of claudication. Nursing care should be directed to avoiding which of the following situations?
- A. Oxygen demand by the muscle exceeds the supply
- B. Oxygen demand and supply of the working muscle are in balance
- C. Oxygen supply exceeds the demand of the working muscle
- D. Oxygen is absent
Correct Answer: A
Rationale: Claudication in PVD results from insufficient blood flow to muscles during activity, causing oxygen demand to exceed supply, leading to pain. Nursing care should aim to improve blood flow (e.g., through exercise programs or medications) and avoid situations where muscle oxygen demand outstrips supply. Balanced or excess supply is desirable, and complete oxygen absence is not typical in claudication.
The nurse is developing the discharge teaching plan for a client after a lumbar laminectomy L4-5 who will be returning to work in 6 weeks. Which of the following actions should the nurse encourage the client to avoid?
- A. Placing one foot on a stepstool during prolonged standing.
- B. Sleeping on the back with support under the knees.
- C. Maintaining average body weight for height.
- D. Sitting whenever possible.
Correct Answer: D
Rationale: Prolonged sitting can stress the surgical site and delay healing post-laminectomy.