Difficulty: Medium
Average Score: 88%
Simulated
Passage / Scenario
Laboratory ResultsVital Signs
0900:
Client reports, "I'm bloated and my stomach hurts."
History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal.
Past medical history: Osteoarthritis.
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco.
Current medications: Ibuprofen 800 mg three times daily PRN arthritis pain.
Physical Examination:
General: client appears uncomfortable, diaphoretic.
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale.
Respiratory: bilateral breath sounds clear.
Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding
Neurological: oriented x 3 (person, place, and time).
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
Correct answer
A,B,C
Rationale
Staying with the client for the first 15 min is indicated to monitor for adverse reactions, which are most likely during this period. Documenting the transfusion is indicated for legal and ethical accountability, recording type, amount, duration, and outcome. Obtaining the blood unit is indicated but should occur before starting the transfusion to ensure compatibility and availability. Titrating the infusion rate to maintain blood pressure is not indicated, as it risks fluid overload or hemolysis; the rate should be based on the client's condition and response. Starting lactated Ringer's is not indicated, as it may cause electrolyte imbalances or hemolysis; only 0.9% NaCl is compatible with blood products.