Ticket to clinical 8 *
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse plan to take?
Check the client's vital signs every hour during the transfusion.
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?
4 hr The nurse should infuse the packed RBCs for no longer than 4 hr due to temperature inconsistencies that develop over time and the possibility of bacterial contamination.
A nurse is preparing to administer blood to a client. The unit of blood on hand is type negative, and the client has type A positive blood. Which of the following actions should the nurse take?
Administer the blood is ordered. The nurse should administer the blood as ordered. Type O blood is compatible with Type A. Type O blood is considered a universal donor as it contains no antigens to react to transfused blood.
A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?
Dyspnea
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
Hemolytic
A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. Which of the following actions is the nurse's priority?
Stop the infusion.
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
Temperature
A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
The first 15 minutes.
A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?
dyspnea
A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification?
identification wristband This is the best option of the four to ensure that the nurse will deliver the correct unit of blood to the client to whom the provider prescribed it. Thus, this is the nurse's highest priority.
