which intervention should the nurse implement for a patient receiving a blood transfusion

ATI RN

ATI Capstone Comprehensive Assessment B

1. What intervention should the nurse implement for a patient receiving a blood transfusion?

A. Administer antihistamines to prevent allergic reactions.
B. Monitor the patient for signs of circulatory overload.
C. Ensure the blood transfusion is completed within 4 hours.
D. Check the patient's vital signs every 30 minutes during the transfusion.

Correct answer: B

Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.

2. What is the most appropriate action for handling hazardous drugs?

A. Wear gloves and wash hands after handling.
B. Store the drugs according to manufacturer instructions.
C. Discard unused drugs in regular trash.
D. Wear personal protective equipment (PPE) when handling hazardous drugs.

Correct answer: D

Rationale: The most appropriate action when handling hazardous drugs is to wear personal protective equipment (PPE) to protect oneself from exposure to the harmful substances. Gloves and handwashing are important but may not provide sufficient protection from hazardous drugs. Storing drugs correctly and disposing of unused drugs properly are also essential, but the primary focus should be on using PPE to prevent exposure.

3. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?

A. Aspirate for a blood return before depressing the plunger
B. Insert the needle at a 45-degree angle
C. Administer the medication 2.54 cm (1 in) from the umbilicus
D. The nurse should not expel the air bubble in the prefilled syringe

Correct answer: D

Rationale: The correct action when administering enoxaparin is not to expel the air bubble in the prefilled syringe. Expelling the air bubble may lead to the loss of medication and result in an incomplete dose. Aspirating for a blood return (Choice A) is not necessary for subcutaneous injections like enoxaparin. Inserting the needle at a 45-degree angle (Choice B) is not specific to administering enoxaparin. Administering the medication 2.54 cm (1 in) from the umbilicus (Choice C) is not a standard guideline for enoxaparin administration.

4. A nurse is preparing to administer medications to four clients. The nurse should administer medications to which client first?

A. A client who has pneumonia and a WBC count of 11,500/mm3 prescribed piperacillin
B. A client who has renal failure and a serum potassium of 5.8 mEq/L prescribed sodium polystyrene sulfonate
C. A client who is post-coronary artery bypass graft (CABG) prescribed atorvastatin
D. A client who has anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa

Correct answer: B

Rationale: The correct answer is B. The client with renal failure and high potassium levels requires immediate attention because hyperkalemia can lead to life-threatening cardiac complications. Administering sodium polystyrene sulfonate helps lower the potassium levels. Choice A, the client with pneumonia and a high WBC count, although important, does not present an immediate life-threatening condition. Choice C, the post-CABG client prescribed atorvastatin, and Choice D, the client with anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa, do not require immediate intervention compared to managing hyperkalemia in a client with renal failure.

5. Which nursing action is essential when administering a blood transfusion?

A. Ensure the blood is administered within 4 hours.
B. Check the patient's vital signs every 30 minutes during the transfusion.
C. Administer the transfusion at a slow rate for the first 15 minutes.
D. Document the transfusion in the patient's medical record immediately after administration.

Correct answer: C

Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.