the nurse is preparing to administer 2 units of packed red blood cells prbcs to a client which action should the nurse implement to ensure the clients
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Nursing Elites

HESI RN

HESI Fundamentals Quizlet

1. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client’s safety?

Correct answer: D

Rationale: Verifying the blood type and crossmatch with another licensed nurse is crucial to prevent transfusion reactions and ensure the client's safety. This step helps confirm that the correct blood type is being transfused to the client, reducing the risk of adverse reactions and promoting safe care. Obtaining informed consent (Choice A) is important but not directly related to ensuring the safety of the transfusion. Reviewing the client's medical history for transfusion reactions (Choice B) is relevant but not as crucial as verifying the blood type and crossmatching. Assessing baseline vital signs (Choice C) is a routine practice before transfusion but ensuring the correct blood type is a higher priority.

2. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?

Correct answer: B

Rationale: The correct calculation involves dividing the total volume by the total time. In this case, 250 ml/4 hours = 63 ml/hour. The dose of KCl is not used in the calculation as the focus is on the rate of infusion over the specified time period. Choice A (13 ml/hour) is incorrect as it does not result from the correct calculation. Choice C (80 ml/hour) and Choice D (125 ml/hour) are also incorrect calculations and do not match the correct rate of infusion required.

3. UAP has lowered the head of the bed to change the linens for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse?

Correct answer: D

Rationale: Purulent drainage indicates infection at the insertion site, which requires immediate attention to prevent complications.

4. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

Correct answer: A

Rationale: The correct instruction for the nurse to provide is to advise the client to decrease intake of fluids after the evening meal. By reducing fluid intake before bedtime, the client can minimize the need to void during the night, which can help improve sleep patterns affected by nocturia. Choices B, C, and D are incorrect. Drinking cranberry juice or warm decaffeinated beverage at bedtime may increase fluid intake, exacerbating the nocturia issue. Consulting the healthcare provider about a sleeping pill should not be the first intervention, as it is important to try non-pharmacological approaches first.

5. A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What type of insulin should the nurse prepare to administer to this client?

Correct answer: A

Rationale: In a client with a blood glucose level of 600 mg/dL, which indicates severe hyperglycemia or diabetic ketoacidosis, the nurse should prepare to administer regular insulin (A). Regular insulin has a rapid onset of action and is the preferred choice for immediate correction of high blood glucose levels. NPH insulin (B), lispro insulin (C), and glargine insulin (D) are not suitable for the rapid correction of severe hyperglycemia.

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