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NCLEX EXAM Dec 14, 2025 ★★★★★ (5.0/5)
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Helena Farentano, 79 years old, is being admitted to the hospital for evaluation of weakness and lightheadedness. While gathering subjective data, the nurse discovers that Helena has experienced frequent episodes of weakness and lightheadedness over the past 3 weeks. Helena tells the nurse that she was brought to the hospital by her son after such an episode this morning, during which she fell. She tells the nurse that she is a widow and lives alone but that her son lives close by and helps her with whatever she needs. Helena's temperature is 99° F (37.2° C), apical pulse is 92 beats/min, respiratory rate is 22 breaths/min, and blood pressure is 100/58 mm Hg. Helena tells the nurse that she has generally been in good health and usually eats a balanced diet but that over the past 3 months or so her appetite has been poor. Laboratory studies and diagnostic tests have been prescribed.While reviewing the results of Helena’s laboratory studies, the nurse notes that Helena’s hemoglobin is 6.8 g/dL (68 mmol/L) and her hematocrit is 24%.The nurse reports the results to the health care provider, who prescribes a transfusion of 1 unit of packed red blood cells (RBCs). Which are part of the correct procedures for administering the blood ? Select all that apply.Using a 22-gauge needle to infuse the blood Monitoring Helena for circulatory overload during the infusion Planning to ensure that the infusion will be complete in 4 hours Monitoring Helena closely for a transfusion reaction, especially during the first 50 mL of the transfusion Ensuring that the transfusion is started within 1 hour of the blood bag’s delivery to the nursing unit from the blood bank.

RATIONALE:

The normal hemoglobin reading in a female client is approximately 12 to 15 g/dL, and the normal hematocrit is 35% to 47%. To avoid septicemia, the transfusion time should not exceed 4 hours. If the client’s size or condition does not allow infusion within 4 hours, the blood bank may split the unit into smaller portions. Helena will be monitored for circulatory overload because of she is 79 years of age; older client is one population at risk for circulatory overload. Although a transfusion reaction can occur at any time, it most likely occurs with the first 15 minutes or first 50 mL of infused solution. Blood bank regulations prevent the return of components to the blood bank inventory that has been warmed to more than 50° F, so 30 minutes is considered to be the maximum time out of monitored storage in most hospitals. The gauge of the needle used for transfusion varies with the product being infused. Generally a 19-gauge or larger needle is required This study source was downloaded by 100000816734524 from CourseHero.com on 04-27-2023 22:06:35 GMT -05:00 https://www.coursehero.com/file/192153734/Question-for-pt-Helena-Farentanodocx/

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Category: NCLEX EXAM
Added: Dec 14, 2025
Description:

Helena Farentano, 79 years old, is being admitted to the hospital for evaluation of weakness and lightheadedness. While gathering subjective data, the nurse discovers that Helena has experienced fr...

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