A nurse preparing to start a blood transfusion will use which type of tubing?
An air vent to let bubbles into the blood
One with a filter to ensure that clots do not enter the patient
An injection port to mix additional electrolytes into the blood
Two-way valves to allow the patient's blood to mix and warm the blood transfusing
The Correct Answer is B
A. An air vent allowing bubbles into the blood would be unsafe and can cause air embolism, so this option is incorrect.
B. Using tubing with a filter is standard practice for blood transfusions to prevent clots and debris from entering the patient’s bloodstream, making this the correct choice.
C. Mixing additional electrolytes into the blood is not a standard practice during transfusions, as it can cause complications; thus, this option is not appropriate.
D. Two-way valves are not typically used in blood transfusion setups; the goal is to keep the blood product separate from other fluids unless specifically indicated.
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Correct Answer is B
Explanation
A. A patient with hypercapnia requires monitoring, but wearing an oxygen mask indicates some level of intervention is in place.
B. A patient with a chest tube should never ambulate with the chest tube unclamped, as this can lead to a collapsed lung and respiratory distress; thus, this patient should be prioritized.
C. While a patient with thick secretions may need suctioning, this is not as critical as ensuring the safety of a patient with an unclamped chest tube.
D. A patient with a new tracheostomy requires monitoring, but the presence of the obturator indicates readiness for emergencies; this does not take priority over the safety of the patient with the chest tube.
Correct Answer is C
Explanation
A. Certification relates to additional qualifications and does not directly involve independent nursing actions in patient care.
B. Licensure is the legal permission to practice nursing but does not describe decision-making and action in patient care.
C. Autonomy is demonstrated when the nurse independently assesses the patient’s fluid status and takes action to promote health by encouraging fluid intake. This reflects the nurse’s ability to make decisions and act based on professional judgment.
D. Accountability refers to being responsible for one's actions but does not specifically cover the independent decision-making shown here.