The nurse infuses a unit of whole blood but, after 4 hours, the blood infusion is not complete. Which should the nurse implement?
1. Check IV access for patency.
2. Increase infusion rate of blood.
3. Discontinue the blood infusion.
4. Assess client for ABO mismatch.
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3. The nurse infuses whole blood within a 4-hour time limit; thus, if the infusion is incomplete at the end of 4 hours, the nurse must discontinue the infusion to decrease the risk of adverse transfusion effects because the blood has sufficiently warmed to promote microorganism growth.
1. Checking the IV access for patency is a reasonable intervention because at the end of 4 hours the IV access is likely to have fibrin deposits or small accumulations im-peding infusion rates. Nevertheless, the nurse must discontinue the blood because it is expired and not safe to infuse.
2. The nurse avoids increasing the infusion rate to complete the transfusion because it increases the risk of fluid volume overload.
4. Although delayed transfusion reactions occur, if a mismatch exists between the blood and the client, the client is more likely to manifest reaction within the first few minutes of the transfusion because this is when most transfusion reactions occur.
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The nurse is calling report to the emergency room from a long-term care facility. The nurse states that the client abruptly experienced a change in mentation including disorientation and confusion
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Based on the information shown in the accompanying figure and obtained for a patient in the emergency room, which action will the nurse take first?
a. Administer the prescribed morphine 4 mg IV. b. Contact the operating room to schedule surgery. c. Check the patient's oxygen saturation using pulse oximetry. d. Ask the patient about the date of the last tetanus immunization.
Mr. Porter is a resident at Spruce Harbor Nursing Center. His wife now needs nursing center care. OBRA requires that:
a. Mrs. Porter goes to a different center. b. Mr. and Mrs. Porter have separate rooms. c. Mr. and Mrs. Porter have separate beds. d. Mr. and Mrs. Porter share the same room if they wish to.