A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?
2 hr
8 hr
6 hr
4 hr
The Correct Answer is D
A. 2 hr: While some patients may tolerate faster infusion rates, the maximum safe time is 4 hours, and there is no requirement to complete it in 2 hours.
B. 8 hr: Blood cannot be left out for 8 hours due to the increased risk of bacterial growth and contamination.
C. 6 hr: Infusing blood over 6 hours exceeds the safe time limit and poses a risk of bacterial contamination.
D. 4 hr: To reduce the risk of bacterial contamination, a unit of packed RBCs must be transfused within 4 hours of starting the infusion. This time frame ensures that the blood remains safe for the patient while minimizing exposure to room temperature.
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Correct Answer is C
Explanation
A. Hip: While “hip” can sometimes colloquially refer to the iliac crest, it is not commonly used to describe the specific site for aspiration outside of the iliac crest.
B. Cervical spine: The cervical spine is not a site used for bone marrow aspiration due to its inaccessibility and proximity to critical structures.
C. Sternum: The sternum is a common site for bone marrow aspiration in adults as it provides direct access to the marrow.
D. Humerus: The humerus is generally not used for bone marrow aspirations as it does not provide as accessible or large an area for aspiration.
Correct Answer is D
Explanation
A. Explain the procedure to the patient’s family: While helpful, this is not as crucial as ensuring patient comfort and pain management during the procedure itself.
B. Observe the patient for bleeding: Observing for bleeding is important post-procedure rather than beforehand.
C. Drape the biopsy site: Draping is part of the procedure setup, but pain management is more critical for patient preparation.
D. Administer an analgesic to the patient: Administering an analgesic is essential to manage pain and discomfort during a bone marrow biopsy. This ensures the patient is as comfortable as possible.