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Author Question: The patient is to receive 2 units of packed RBCs. Before administering the blood, what does the ... (Read 363 times)

Wadzanai

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The patient is to receive 2 units of packed RBCs. Before administering the blood, what does the nurse need to do? (Select all that apply.)
 
  a. Insert an 18-gauge IV cannula.
  b. Have the patient complete a consent form.
  c. Obtain pretransfusion vital signs.
  d. Notify the physician for a temperature of 37 C.

Question 2

A client with a cognitive deficit becomes agitated and upset about not being able to remember daily activities. The nurse should:
 
  A. Tell the client not to worry about it
  B. Provide an easy-to-follow calendar and reinforce the information
  C. Explain that becoming upset is not going to help the situation and that staying calm may help the memory
  D. Remind the client that he or she has had many years of responsibility and now is his or her time to rest and relax



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hanadaa

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Answer to Question 1

B, C
In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Check that the patient has properly completed and signed transfusion consent before retrieving blood. Most agencies require patients to sign consent forms before receiving blood component therapy because of the inherent risks. Obtain and record pretransfusion vital signs, including temperature, immediately before initiation of the transfusion. If the patient is febrile (temperature greater than 100 F 37.8 C), notify the physician or the health care provider before initiating the transfusion. Change from baseline vital signs during infusion will alert the nurse to a potential transfusion reaction or adverse effect of therapy.

Answer to Question 2

B
B. Have a large calendar posted in a conspicuous area to write in appointments or special planned events.
A. Telling the client not to worry negates the client's feelings.
C. This response is false reassurance and not helpful to the client.
D. This response negates the client's feelings and fears.





 

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