Nokea
A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
- A. 4 hr
- B. 2 hr
- C. 8 hr
- D. 6 hr
Correct Answer: A
Rationale: The total infusion time for packed RBCs should not exceed 4 hours to minimize the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications. Infusing beyond 4 hours increases this risk significantly.
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Nurse's Notes:
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, the client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distention noted.
Vital signs:
Temperature: 37.0°C (98.6°F)
Heart Rate (HR): 110 beats per minute
Blood Pressure (BP): 150/90 mmHg
Respiratory Rate (RR): 24 breaths per minute
Oxygen Saturation (SpO2): 92% on 2L nasal cannula
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Administer diphenhydramine, Administer an antibiotic, Administer furosemide, Stop transfusion
- B. Transfusion reaction, Transfusion associated circulatory overload, Acute extravasation
- C. Hives, Weight, Low back pain, Respiratory rate
Correct Answer: B,C,D
Rationale: The client is experiencing transfusion-associated circulatory overload (TACO), indicated by dyspnea, crackles, jugular vein distention, and hypertension. Stopping the transfusion prevents further fluid overload, and furosemide removes excess fluid. Monitoring weight and respiratory rate assesses fluid status and respiratory distress.
A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify which of the following persons is qualified?
- A. Phlebotomist
- B. Assistive personnel
- C. Senior nursing student
- D. Oncology nurse
Correct Answer: D
Rationale: An oncology nurse is a registered nurse with specialized training and experience in administering blood products, making them qualified to double-check blood labels and patient identification. Phlebotomists, assistive personnel, and senior nursing students lack the required training or authority for this critical safety task.
In reviewing a patient's complete blood count (CBC) results, the nurse notes a 'shift to the left.' What is the significance of these results?
- A. There is an elevated number of immature thrombocytes.
- B. There is an elevated number of immature neutrophils (bands),
- C. There is an elevated number of mature neutrophils (segs)
- D. There is an elevated number of mature erythrocytes
Correct Answer: B
Rationale: A 'shift to the left' indicates an increase in immature neutrophils (bands), often signaling acute infection or inflammation as the body releases more neutrophils to fight pathogens.
A charge nurse is teaching a newly licensed nurse about risk factors for chronic myelogenous leukemia (CML). Which of the following information should the nurse include?
- A. Exposure to radiation
- B. Family history
- C. Another type of cancer
- D. Genetic mutation
Correct Answer: A
Rationale: Exposure to high levels of radiation is a known risk factor for CML, as seen in historical data from atomic bomb survivors. Family history and other cancers are not significant risk factors, and the Philadelphia chromosome mutation is an acquired, not inherited, genetic factor.
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
- A. Anorexia and malnutrition
- B. Diarrhea and dehydration
- C. Bleeding from the gums
- D. Full body alopecia
Correct Answer: C
Rationale: Myelosuppression can cause thrombocytopenia, increasing bleeding risk, including from gums. Anorexia, diarrhea, and alopecia are chemotherapy side effects but not directly related to myelosuppression.