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:
Answer(s): A
(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:
Answer(s): B
(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 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for:
Answer(s): D
(A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a priority nursing diagnosis postoperatively. (B) The client will have a Foley catheter for a day or two after surgery. Urinary retention is usually not a problem once the Foley catheter is removed. (C) A client having a cholecystectomy should not be physically impaired. In fact, the client is encouraged to begin ambulating soon after surgery. (D) Because of the location of the incision, the client having a cholecystectomy is reluctant to breathe deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.
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