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N230 Ch31 NCLEX Practice Exam With Complete Solution
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N230 Ch31 NCLEX Practice Exam With Complete Solution...
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N230 Ch31 NCLEX Practice Exam With Complete SolutionThe nurse is caring for a client who has metastatic cancer. The client's hemoglobin is
8.7 g/dL and hematocrit is 26%. The nurse should prioritize beginning interventions to
minimize:
Thirst
Fatigue
Headache
Abdominal pain - ANSWER -Fatigue
The patient is anemic due to a low hemoglobin and hematocrit; hence, this patient would
most likely complain of fatigue. Fatigue develops because of the lowered
oxygen-carrying capacity, which results in reduced tissue oxygenation in order to carry
out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.
The nurse is caring for a patient who is to receive a transfusion of two units of packed
red blood cells. After obtaining the first unit from the blood bank, the nurse would ask
which health team member in the nurses' station to assist in checking the unit before
administration?
Unit secretary
A physician's assistant
Another registered nurse
An unlicensed assistive personnel - ANSWER -Another registered nurse
Before hanging a transfusion, the registered nurse must check the unit with another RN
or with a licensed practical (vocational) nurse, depending on agency policy. The unit
secretary, physician's assistant, or unlicensed assistive personnel should not be asked.
Prior to the transfusion of packed red blood cells for an older anemic patient, how many
, minutes would a nurse delegate to a coworker to check on his or her other patients
once the nurse has started the transfusion?
-5
-15
-30
-60 - ANSWER -15
By routine, the nurse is to remain with the patient for the initial 15 minutes of the start of
a blood transfusion. For those patients who are going to have a transfusion reaction, it is
in the initial 15-minute period that the manifestations would occur to show that there is
an infusion of blood. Frequency during infusion would be every 30 to 60 minutes.
When preparing to administer an ordered blood transfusion, which IV solution does the
nurse use when priming the blood tubing?
-Lactated Ringer's
-5% dextrose in water
-0.9% sodium chloride
-0.45% sodium chloride - ANSWER -0.9% sodium chloride
The blood set should be primed before the transfusion with 0.9% sodium chloride, often
called normal saline. It is also used to flush the blood tubing at the end of the infusion so
the patient can receive blood still in the tubing when the bag is empty. Dextrose and
lactated Ringer's solutions cannot be used with blood because they will hemolyze the
RBCs.
The nurse reads a physician order written at 10:00 AM to transfuse an anemic client who
has been experiencing chronic blood loss with two units of packed red blood cells. At
11:30 AM the nurse is notified that the first unit of the transfusion is ready to be picked
up from the transfusion service. By what time should the nurse plan to hang the unit no
later than?
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