The nurse is preparing to initiate a blood transfusion. Which step of the procedure should the nurse implement first?
a. Begin the infusion at 2 mL/min.
b. Establish a single-line infusion.
c. Check vital signs in 30 minutes.
d. Shake the blood gently to mix the preser-vative.
A
The nurse initiates infusion of the blood very slowly at 2 mL/min to prevent the infusion of a large volume bolus of potentially incompatible blood. Most transfusion reactions occur during the first 15 minutes of the infusion; thus the nurse continues the slow rate for 15 minutes while closely monitoring the patient for a transfusion reaction. The nurse needs to infuse blood prod-ucts through a Y-tubing administration set. The nurse evaluates the patient's vital signs within 5 minutes of starting the infusion for 15 minutes and then every 15 minutes or according to agency policy. The nurse avoids shaking blood products because violent movement damages erythro-cytes and increases their hemolysis.
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What is the social orientation among most middle-class American families?
a. Extended b. Friends c. Significant others d. Nuclear
For the patient whose nursing diagnosis is Powerlessness related to an inability to control compulsive cleaning, the nurse must understand that the patient uses the cleaning to:
a. enhance her self-esteem. b. reduce spread of illnesses. c. exert control over her anxiety. d. distract herself from her anxiety.
A nurse is caring for a client with congestive heart failure (CHF) who currently smokes cigarettes and has a 50 pack-year smoking history
When providing smoking cessation education to the client, which statements regarding the pathophysiology of nicotine use are appropriate? Select all that apply. A) "In low doses, nicotine stimulates nicotinic receptors in the brain to release dopamine." B) "In high doses, nicotine stimulates the parasympathetic system to release epinephrine, causing vasoconstriction." C) "Initially, nicotine increases mental alertness and cognitive ability." D) "Nicotine is a nonpsychoactive substance found in tobacco." E) "Gradual reduction of nicotine appears to be the best method of cessation."
Discharge planning requires all of the following except:
a. assessing the patient's plan of care to determine whether the outcome criteria are met. b. evaluation of whether the patient and family can continue with the necessary in-terventions or whether they need assistance. c. obtaining specific orders from the physician to begin the process of discharge planning. d. assessing the level of the patient's understanding with regard to his or her illness state and treatment regimen.