Free NCLEX-RN Exam Braindumps (page: 187)

Page 187 of 431

A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:

  1. Take a baseline set of vital signs
  2. Hang Ringer's lactate as the companion fluid
  3. Use microdrip tubing for the blood administration
  4. Have the registered nurse in charge assume responsibility for verifying the client and blood product information

Answer(s): A

Explanation:

(A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. (B) The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. (C) Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. (D) Proper identification of the recipient and the blood product must be validated by at least two people.



A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:

  1. Take a baseline set of vital signs
  2. Hang Ringer's lactate as the companion fluid
  3. Use microdrip tubing for the blood administration
  4. Have the registered nurse in charge assume responsibility for verifying the client and blood product information

Answer(s): A

Explanation:

(A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. (B) The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. (C) Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. (D) Proper identification of the recipient and the blood product must be validated by at least two people.



A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:

  1. Suction for a maximum of 20 seconds
  2. Hyperoxygenate before and after suctioning
  3. Suction for a maximum of 30 seconds
  4. Maintain clean technique during suctioning

Answer(s): B

Explanation:

(A) The maximum time for suctioning is 10­15 seconds. (B) Supplemental O2should be administered before and after suctioning to reduce hypoxia. (C) The maximum time for suctioning is 10­15 seconds. (D) Strict sterile technique should be used during suctioning.



A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:

  1. Suction for a maximum of 20 seconds
  2. Hyperoxygenate before and after suctioning
  3. Suction for a maximum of 30 seconds
  4. Maintain clean technique during suctioning

Answer(s): B

Explanation:

(A) The maximum time for suctioning is 10­15 seconds. (B) Supplemental O2should be administered before and after suctioning to reduce hypoxia. (C) The maximum time for suctioning is 10­15 seconds. (D) Strict sterile technique should be used during suctioning.



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