Critical Care- NCLEX

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? - Vital signs Rationale: A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important. A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings? - Transfusion reaction Rationale: The signs and symptoms exhibited by the client are consistent with a transfusion reaction. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. With fluid (circulatory) overload, the client would have crackles in addition to dyspnea. There is no correlation between the signs mentioned in the question and hypovolemic shock. The signs identified in the question are indicative of an allergic reaction, which is one type of blood transfusion reaction. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? - The blood bank Rationale: The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented. The remaining options are incorrect. The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place? - The blood will be held, and the primary health care provider (PHCP) will be notified. Rationale: If the client has a temperature of 100° F (37.7° C) or more, the unit of blood should be held until the primary health care provider (PHCP) is notified and has the opportunity to give further prescriptions. The other options are incorrect actions. The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? - Infiltration Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The other options identify complications that are likely to be accompanied by warmth at the site rather than coolness. The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? - Phlebitis of the vein Rationale: Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV line should be inserted at a different site. The remaining options are incorrect; the signs and symptoms in the question are not associated with these conditions. The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? - Sterile 2 × 2 gauze Rationale: A dry, sterile dressing such as sterile 2 × 2 gauze is used to apply pressure to the site while the catheter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A Band-Aid may be used to cover the site after hemostasis has occurred. An alcohol swab or Betadine would irritate the opened puncture site and would not stop the blood flow. A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? - 15 minutes Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most likely time that a transfusion reaction will occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other clients during this time. Five minutes is too short of a time period, while 30 and 45 minutes are lengthy time periods. The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? - Chills, itching, or rash Rationale: The client is told to report chills, itching, or rash immediately, because these could be signs of a possible transfusion reaction. Mild discomfort at the catheter site may be indicative of a problem, or it could result from the size of the IV catheter required to infuse the blood product. Sore throat, earache, sleepiness, and fatigue are unrelated to a transfusion reaction. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? - A decrease in oozing from puncture sites and gums Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes. The client's temperature would decline to normal after the infusion of granulocytes if those transfused cells were then instrumental in fighting infection in the body. Increased hemoglobin and hematocrit levels would be seen when the client has received a transfusion of red blood cells. A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? - Call the poison control center. Rationale: If a suspected poisoning occurs, the poison control center should be contacted immediately. The nurse can assist the mother with contacting the poison control center. Vomiting should not be induced without instructions from the poison control center. Inducing vomiting is not done if the client is unconscious or the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would delay treatment. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance. The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first? - Clear and maintain an open airway. Rationale: The first actions are to maintain an open airway and to prevent injuries to the client. The client should be turned to the side and monitored for airway compromise. Options 1, 3, and 4 may be components of care, but they are not the first actions. The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? - Turn the client onto her side. Rationale: With a pregnant client who is in shock, the nurse should want to increase perfusion to the placenta to minimize fetal distress. A simple way to do this that requires no equipment is to turn the mother on her side. This increases blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. The nurse should immediately contact the registered nurse, who then contacts the health care provider. The other options should follow quickly.