Which nursing interventions are appropriate for a nurse administering a blood transfusion? [Select All That Apply]
Hang a bag of 0.9% normal saline with 5% dextrose at the bedside (D5%NS)
Verify the client's name and blood type with a second nurse
Infuse the unit of blood within 4 hours.
Obtain baseline vital signs prior to starting the transfusion
Continuously monitor the client during the first 15 minutes of the transfusion
Insert an 18-gauge intravenous catheter
Insert a 22-gauge intravenous catheter
Correct Answer : B,C,D,E,F
A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.
B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.
C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.
D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.
E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.
F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.
G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.
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Correct Answer is B
Explanation
A. While deep breathing can help alleviate pain, it is not the primary cause of pain in sickle cell anemia; this response could minimize the client's experience.
B. Sickle cell anemia causes red blood cells to become rigid and shaped like a sickle, which can obstruct blood flow and lead to vaso-occlusive crises, resulting in pain.
C. Although sickle cell anemia is a genetic disorder, simply stating that the mutated gene causes increased pain is too vague and does not explain the pain mechanism adequately.
D. While anemia can contribute to fatigue and some discomfort, the pain in sickle cell anemia is primarily due to the sickling of red blood cells and subsequent blockage of blood flow, rather than just the lack of hemoglobin.
Correct Answer is B
Explanation
A. While legumes are a good source of protein, they do not provide the high-calorie density needed for someone experiencing wasting syndrome.
B. Consuming high-calorie snacks between meals is the most appropriate suggestion as it helps increase overall caloric intake, which is essential for clients with wasting syndrome to help maintain weight and improve nutritional status.
C. Using canola oil instead of butter may not significantly impact caloric intake, and clients with wasting syndrome may need higher-calorie options.
D. Adding celery to soups or salads adds volume but is low in calories and may not contribute significantly to the dietary needs of someone experiencing wasting syndrome.