NURS 3411 Adult Health 1

A nurse is providing teaching to a client who is scheduled to receive one unit of packed RBCs. Which of the following information should the nurse include in the teaching? "It will take approximately 6 hours for this unit of blood to infuse" "You can expect to experience some back discomfort during the infusion" "You will need to lie on your side while the blood is infusing" "I will remain with you for the first 15 minutes of the transfusion process"

"I will remain with you for the first 15 minutes of the transfusion process" The nurse should inform the client that they will remain with the client for the first 15 min of the transfusion. It is during the first 50 mL of the transfusion that a severe reaction is most likely to occur.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? Wean the patient from the TPN solution when oral intake is 40% of caloric requirements Shake the TPN solution prior to administration if it contains oily globules Remove the TPN solution from the refrigerator 1 hour prior to infusion Discard the patient's remaining TPN solution within 24 hours of beginning the infusion, rather than 48 hours

Remove the TPN solution from the refrigerator 1 hour prior to infusion The nurse should remove the TPN solution from the refrigerator 1 hr prior to administration because the TPN should reach room temperature before it is infused.

A nurse is providing discharge education to the caregiver of a client who will be receiving total parenteral nutrition (TPN) at home. Which of the following statements by the caregiver indicates an understanding of the teaching? "Oral feedings can begin when TPN is discontinued" "I will start and stop the feedings at the same rate" "We can administer the TPN during the night" "We should obtain weight measurements every 3 days for the first month of TPN"

"We can administer the TPN during the night" The caregiver and patient may choose to administer TPN during the night to allow the client to be more independent during daytime hours. Therefore, the nurse should recognize that this statement indicates an understanding of TPN administration

A nurse is planning to administer total parenteral nutrition (TPN) with 10% dextrose to a newly-admitted patient. Which of the following actions should the nurse plan to take? Obtain the patient's blood glucose every 12 hours Verify the patient's infusion rate every 8 hours Weigh the patient every 48 hours Change the patient's IV catheter tubing every 24 hours

Change the patient's IV catheter tubing every 24 hours The nurse should change the client's IV catheter tubing every 24 hr to protect the client from bacterial and fungal growth, which can cause infection.

A nurse is preparing to hang a new bag of total parenteral nutrition (TPN) for a client and discovers that it has not arrived from the pharmacy. Which of the following available solutions should the nurse infuse until the client's TPN arrives? Lactated Ringer's Dextrose 5% in 0.225% saline 0.9% saline Dextrose 10% in water

Dextrose 10% in water The nurse should infuse dextrose 10% or 20% in water if the client's TPN solution is temporarily unavailable. Dextrose 10% in water is a hypertonic solution and contains 340 cal per liter. Abruptly stopping TPN can cause hypoglycemia. Therefore, infusing dextrose 10% in water temporarily at the same rate as the TPN can prevent this adverse effect.

A nurse is reviewing the serum levels of a patient who is receiving total parenteral nutrition (TPN). The nurse should identify which of the following laboratory findings as an adverse effect of the TPN? Potassium 3.9 mEq/L Glucose 129 mg/dL Sodium 138 mEq/L Calcium 9.5 mg/dL

Glucose 129 mg/dL A serum glucose level of 129 mg/dL is above the expected reference range of 74 to 106 mg/dL. Therefore, this value indicates hyperglycemia, which is a potential adverse effect of TPN due to the hyperosmolarity of the plasma, and may result in osmotic diuresis. The hyperosmolarity is caused by amino acid and dextrose concentrations in the TPN. The increased dextrose in turn causes increased blood glucose (hyperglycemia).

A nurse is preparing to administer one unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse take? Prime the Y-line tubing with dextrose 5% in water Obtain the client's vital signs 30 min prior to blood administration Have a second nurse assist with comparing the client's identification information Ask the client to empty their bladder prior to the transfusion

Have a second nurse assist with comparing the client's idenfication information It is the responsiblity of the nurse who will be administering the blood product to enlist a second nurse to compare the client's identification with the information on the blood component bag.

A nurse is caring for a client who is receiving a unit of packed RBCs. The client reports experiencing flank pain and feeling their heart racing. The nurse should identify that the client is experiencing which of the following types of transfusion reactions? Allergic Hemolytic Circulatory overload Febrile

Hemolytic The nurse should identify that flank pain and tachycardia are manifestations of a hemolytic transfusion reaction. Other manifestations can include fever, chills, hypotension, apprehension, and reddish or brown urine.

A nurse is preparing to administer platelets to a client who has thrombocytopenia. Which of the following actions should the nurse take? Use a transfusion set that has a short tubing and a small filter Verify the client's blood type with a second nurse Allow platelets to sit at room temperature for 1 hour prior to infusion Infuse the platelets over a period of 2 hours

Use a transfusion set that has a short tubing and a small filter The nurse should administer platelets with a special transfusion set that has a smaller filter and a shorter tubing. If a standard blood administration set is used, the filter can trap the platelets and the longer tubing increases platelet adherence to the lumen.

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? Monitor vital signs every hour during the transfusion Infuse each unit of blood slowly over 6 hours to avoid fluid overload Infuse the blood using an 18-gauge needle Wait 2 hours between infusing the 2 units of packed RBCs

Wait 2 hours between infusing the 2 units of packed RBCs If possible, the nurse should wait 2 hours between the administration of the first unit of packed RBCs before beginning to infuse the second unit. This will decrease the client's risk of fluid overload