NCLEX-PN

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A. You must ensure that the client has a patent intravenous catheter that is at least 20 gauge B. You will need the help of another nurse prior to the administration of these packed red blood cells C. The unit of packed red blood cells should start no more than 1 hour after it is picked up D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins Correct Response : B Explanation : Two nurses must check the blood, the doctor’s order, the ABO compatibility, and the client’s identity using at least two unique identifiers prior to the administration of this blood. You must ensure that the client has a patent intravenous catheter that is at least 18 gauge and not 20 gauge; you will be using normal saline and a Y infusion set for the administration of the blood because Ringer’s lactate and other intravenous solutions are not compatible with blood; blood should not remain in the client care area for more than 30 minutes so it is important that the nurse is prepared to begin the transfusion shortly after the blood is delivered to the client care area; and, lastly, the nurse should remain with and monitor the client for at least 15 minutes after the transfusion begins at a slow rate since most serious blood reactions and complications occur shortly after the transfusion begins. (See Ensuring Accurate Client Identification Before Blood Transfusions ) 10.You are preparing to administer a PRN medication for pain. After your assessment of the client for pain, you open the narcotics cabinet with the special key. Your calculations indicate that the client will be getting 0.8 mLs of the medication, and the unit dose vial is 1 mL. You discard the excess of 0.2 mLs into the sink drain and enter the client’s room. After you identify the client using two unique identifiers, the client refuses the medication. You then discard the 0.8 mLs into the sink and document the client’s refusal on the narcotics count record. What have you failed to do during this process? A. You have failed to have another nurse witness the 0.8 mLs and the 0.2 mLs of waste

B. You have failed to have another nurse witness the 0.8 mLs of waste C. You have failed to have another nurse witness the 0.2 mLs of waste D. You have failed to ask another nurse to verify the calculation of the dosage Correct Response: A

Explanation : All controlled substances are documented on the narcotics record as soon as they are removed, and all controlled substances that are wasted for any reason, either in their entirety or only partially, must be witnessed or documented by the wasting nurse and another nurse. Both nurses document this waste. It should not be necessary for you to ask another nurse to verify this calculation; the nurse is accountable and responsible for accurate dosage calculations. (See Documenting Medication Administration Across All Routes )

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