Nokea
Provider Prescriptions 1230:
0.9% sodium chloride 500 mL bolus then 100 mL/hr.
Type and cross match for 2 units of packed RBCs.
Repeat WBC, hemoglobin, hematocrit STAT.
Delay endoscopy.
2L/min O, via nasal cannula,
1330:
2 units packed RBCs IV over 4 hr.
Repeat WBC, hemoglobin, hematocrit at transfusion completion
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion.
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
- D. Obtain the first unit of packed RBCs from the blood bank.
- E. Start an IV bolus of lactated Ringer's solution.
Correct Answer: B
Rationale: [0, 1, 0, 0]
The correct answer is Stay with the client for the first 15 min of the transfusion. This action is indicated to monitor for adverse reactions such as fever, chills, or signs of hemolysis. Documenting the blood product transfusion (A) is important but not a priority during the initial phase. Titrating the infusion rate (C) and obtaining the blood product (D) are essential, but staying with the client for monitoring takes precedence. Starting an IV bolus (E) is not related to blood transfusion monitoring.
You may also like to solve these questions
A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statements should the nurse include in the teaching?
- A. Diarrhea is a common adverse effect of this medication.
- B. Ringing in the ears is an expected adverse effect of this medication.
- C. Notify your provider if you develop a fever while taking this medication.
- D. You might experience weight loss while taking this medication.
Correct Answer: C
Rationale: The correct answer is C: Notify your provider if you develop a fever while taking this medication. This is important because clozapine can cause a serious condition called agranulocytosis, which can lead to a fever. The nurse should emphasize the significance of monitoring for fever and promptly notifying the healthcare provider. Choice A is incorrect because diarrhea is not a common adverse effect of clozapine. Choice B is incorrect as ringing in the ears is not an expected adverse effect. Choice D is incorrect because weight gain, not weight loss, is a common side effect of clozapine.
A nurse is planning to administer medication to an older adult client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Tilt the client's head back when administering the medications
- B. Mix the medications with a semisolid food for the client
- C. Administer more than one pill to the client at a time
- D. Place the medications on the back of the client's tongue
Correct Answer: B
Rationale: The correct answer is B: Mix the medications with a semisolid food for the client. This is the safest option for a client with dysphagia as it reduces the risk of choking or aspiration. Mixing medications with food can help make swallowing easier and safer for the client. Tilt the client's head back (A) can increase the risk of choking. Administering more than one pill at a time (C) can lead to swallowing difficulties. Placing medications on the back of the tongue (D) can trigger a gag reflex in clients with dysphagia.
A nurse is planning teaching for a client who is trying to quit smoking. Which of the following instructions about nicotine replacement options should the nurse include?
- A. Change the nicotine patch every other day.
- B. Do not drink beverages while sucking on a nicotine lozenge.
- C. Chew nicotine gum for 10 min before spitting it out.
- D. Administer 2 sprays of nicotine nasal spray in each nostril with each dose.
Correct Answer: B
Rationale: The correct answer is B: Do not drink beverages while sucking on a nicotine lozenge. This instruction is important because beverages can interfere with the absorption of nicotine from the lozenge. Nicotine replacement therapy works best when the nicotine is absorbed properly, so avoiding beverages while using the lozenge will help ensure its effectiveness. Changing the nicotine patch every other day (choice A) is incorrect as patches are typically changed daily. Chewing nicotine gum for 10 minutes before spitting it out (choice C) is incorrect as the gum should be chewed until a tingling sensation is felt, then parked between the cheek and gum. Administering 2 sprays of nicotine nasal spray in each nostril with each dose (choice D) is incorrect as the dosage is usually one spray in each nostril.
A nurse is administering 4 mg of hydromorphone to a client by mouth every 4 hr. The medication is provided as hydromorphone 8 mg per tablet. Which of the following actions is appropriate for the nurse to take?
- A. Return the remaining medication to the facility's pharmacy.
- B. Store the remaining half of the pill in the automated medication dispensing system.
- C. Place the remaining half of the pill in the unit dose package.
- D. Dispose of the remaining medication while another nurse observes.
Correct Answer: D
Rationale: The correct answer is D: Dispose of the remaining medication while another nurse observes. This is the appropriate action because hydromorphone is a controlled substance with high abuse potential. The nurse should follow proper medication disposal protocols to prevent diversion or misuse. Returning the medication to the pharmacy (choice A) may not ensure proper disposal. Storing the remaining half of the pill in the automated medication dispensing system (choice B) or placing it in the unit dose package (choice C) could lead to unauthorized access. Disposing of the medication while another nurse observes (choice D) ensures accountability and adherence to safety measures.
A nurse is reviewing a client's 0800 laboratory values at 1100. The nurse notes that the client received heparin at 1000. Which of the following laboratory values warrants an incident report?
- A. ePTT 90 seconds
- B. Hgb 16 g/dL
- C. INR 1.6
- D. WBC 6,000/mm3
Correct Answer: A
Rationale: The correct answer is A: ePTT 90 seconds. This value indicates a higher than normal clotting time, which could potentially lead to bleeding complications due to excessive anticoagulation from heparin. The other values (B, C, D) are within normal ranges and do not indicate an immediate risk or adverse outcome related to heparin administration. An incident report is necessary to document and address the elevated ePTT to ensure appropriate interventions are taken to prevent harm to the patient.