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 with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?

Correct answer: C

Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A) is within an acceptable range for a client with COPD and does not require immediate action. An oxygen saturation of 92% (B) is slightly lower but still acceptable in COPD patients. Although a respiratory rate of 24 (D) is higher, it is not as immediately concerning as shortness of breath in this context.

3. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?

Correct answer: D

Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.

4. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?

Correct answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.

5. While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?

Correct answer: A

Rationale: Option A is the best response as it directly addresses the client's concern about the reduction in sexual drive caused by the medication. It encourages the client to express their thoughts and feelings about how this side effect may impact their current sexual activity, facilitating open communication and understanding between the nurse and the client. Choices B, C, and D are not as appropriate as they do not directly address the client's immediate concern regarding the impact of the medication on their sexual drive.

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