The nurse is assisting with caring for a client who will receive a unit of blood. Just
before the infusion, it is most important for the nurse to check
... [Show More] which item? - Vital
signs
Rationale: A change in the vital signs may indicate that a transfusion reaction is
occurring. The nurse assesses the client's vital signs before the procedure to obtain
a baseline every 15 minutes for the first half hour after beginning the transfusion and
every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit
may be checked but are not the most important.
A client who is receiving a blood transfusion pushes the call light for the nurse. When
entering the room, the nurse notes that the client is flushed, dyspneic, and
complaining of generalized itching. How should the nurse correctly interpret these
findings? - Transfusion reaction
Rationale: The signs and symptoms exhibited by the client are consistent with a
transfusion reaction. With bacteremia, the client would have a fever, which is not part
of the clinical picture presented. With fluid (circulatory) overload, the client would
have crackles in addition to dyspnea. There is no correlation between the signs
mentioned in the question and hypovolemic shock. The signs identified in the
question are indicative of an allergic reaction, which is one type of blood transfusion
reaction.
A client who was receiving a blood transfusion has experienced a transfusion
reaction. The nurse sends the blood bag that was used for the client to which area? -
The blood bank
Rationale: The nurse prepares to return the blood transfusion bag containing any
remaining blood to the blood bank. This allows the blood bank to complete any
follow-up testing procedures that are needed after a transfusion reaction has been
documented. The remaining options are incorrect.
The nurse takes a client's temperature before giving a blood transfusion. The
temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered
nurse (RN) and anticipates that which action will take place? - The blood will be held,
and the primary health care provider (PHCP) will be notified.
Rationale: If the client has a temperature of 100° F (37.7° C) or more, the unit of
blood should be held until the primary health care provider (PHCP) is notified and
has the opportunity to give further prescriptions. The other options are incorrect
actions.
The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site.
The nurse notes that the site is cool, pale, and swollen and that the IV has stopped
running. The nurse determines that which has probably occurred? - Infiltration
Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in
subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid
being deposited into the subcutaneous tissue. When the pressure in the tissues
exceeds the pressure in the tubing, the flow of the IV solution will stop. The other
options identify complications that are likely to be accompanied by warmth at the site
rather than coolness.
The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The
nurse notes the site to be reddened, warm, painful, and slightly edematous in the
area of the vein proximal to the IV catheter. The nurse interprets that this is likely the
result of which? - Phlebitis of the vein
Rationale: Phlebitis at an IV site results in discomfort at the site and redness,
warmth, and swelling proximal to the IV catheter. The IV catheter should be
removed, and a new IV line should be inserted at a different site. The remaining
options are incorrect; the signs and symptoms in the question are not associated
with these conditions.
The nurse has been instructed to remove an intravenous (IV) line. The nurse
removes the catheter by withdrawing the catheter while applying pressure to the site
with which item? - Sterile 2 × 2 gauze
Rationale: A dry, sterile dressing such as sterile 2 × 2 gauze is used to apply
pressure to the site while the catheter is discontinued and removed. This material is
absorbent, sterile, and nonirritating to the site. A Band-Aid may be used to cover the
site after hemostasis has occurred. An alcohol swab or Betadine would irritate the
opened puncture site and would not stop the blood flow.
A client is going to be transfused with a unit of packed red blood cells (PRBCs). The
nurse understands that it is necessary to remain with the client for what time period
after the transfusion is started? - 15 minutes
Rationale: The nurse must remain with the client for the first 15 minutes of a
transfusion, which is the most likely time that a transfusion reaction will occur. This
enables the nurse to detect a reaction and intervene quickly. The nurse engages in
safe nursing practice by obtaining coverage for the other clients during this time. Five
minutes is too short of a time period, while 30 and 45 minutes are lengthy time
periods.
The nurse is assisting with caring for a client who is receiving a unit of packed red
blood cells (PRBCs). The nurse should tell the client that it is most important to
report which sign(s) immediately? - Chills, itching, or rash [Show Less]