A charge nurse is precepting a newly licensed nurse who is to administer a transfusion of packed red blood cells (PRBC) to a client who has anemia. Which of the following actions by the new nurse should cause the charge nurse to intervene in this client's care immediately?

The nurse stays with the client for 15 minutes after beginning the transfusion.

The nurse primes the blood tubing with lactated ringers.

The nurse starts the infusion at a slow rate for the first 15 minutes.

The nurse witnesses the client sign the consent form for the blood transfusion.

Answer and Explanation

The Correct Answer is B

A. The nurse stays with the client for 15 minutes after beginning the transfusion:

This action is appropriate as it ensures the nurse monitors the client closely for any immediate adverse reactions during the initial phase of the transfusion.

B. The nurse primes the blood tubing with lactated Ringer's solution:

This action is incorrect and potentially dangerous. Blood tubing should be primed with normal saline (0.9% sodium chloride) solution, not lactated Ringer's solution, to prevent potential adverse reactions or hemolysis of the blood products.

C. The nurse starts the infusion at a slow rate for the first 15 minutes:

This action is appropriate as it allows for the initial assessment of the client's tolerance to the transfusion and reduces the risk of adverse reactions.

D. The nurse witnesses the client sign the consent form for the blood transfusion:

This action is appropriate and ensures that the client has provided informed consent for the procedure.

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Correct Answer is A

Explanation

A. The test is noninvasive, and nothing will be inserted into the client's body: Transthoracic echocardiography (TTE) is a noninvasive procedure that uses ultrasound waves to create images of the heart. It involves placing a transducer on the chest wall to capture images of the heart's structure and function. The nurse should inform the client that no instruments or devices will be inserted into their body during the test.

B. The client will remain on bed rest for 1 to 2 hours after the test: This statement is not typically accurate for a TTE procedure. After a TTE, clients can usually resume their normal activities without any specific bed rest requirements, unless otherwise specified by the healthcare provider based on individual circumstances.

C. The client's pain will be managed aggressively during the procedure: TTE is generally a painless procedure that does not require aggressive pain management. The client may feel slight discomfort from the transducer's pressure on the chest, but it is typically well tolerated without the need for pain medication.

D. The test will provide a detailed profile of the heart's electrical activity: While echocardiography provides detailed images of the heart's structure and function, including information about blood flow and valve function, it does not directly assess the heart's electrical activity. For evaluating electrical activity, other tests such as electrocardiography (ECG or EKG) would be used.

A. Work together to see how they can incorporate healthier choices into the foods enjoyed. B. Tell the client if they do not change their diet, they are going to have a myocardial infarction. C. Give the client a list of foods to choose from. D. It is okay to cheat because of the medications.

Correct Answer is A

Explanation

A. Work together to see how they can incorporate healthier choices into the foods enjoyed:

This approach emphasizes collaboration between the nurse and the client, focusing on finding ways to incorporate healthier food choices into the client's diet while considering their food preferences and cultural background. By working together, the nurse can help the client identify suitable substitutions, portion control strategies, and meal planning techniques that align with the dietary recommendations for coronary heart disease. This approach promotes active participation, empowers the client to make informed decisions, and increases the likelihood of long-term adherence to the dietary plan.

B. Tell the client if they do not change their diet, they are going to have a myocardial infarction:

This approach uses fear tactics or negative consequences to motivate behavior change, which is generally not recommended in healthcare settings. Fear-based strategies may lead to increased anxiety, stress, or resistance in the client, ultimately hindering motivation and adherence to the dietary plan. Positive reinforcement, education, and collaborative goal-setting are more effective in promoting behavior change and improving adherence to lifestyle modifications.

C. Give the client a list of foods to choose from:

Providing a list of foods can be a helpful tool in guiding food choices and promoting a balanced diet. However, this approach may not address the client's individual preferences, cultural considerations, or practical challenges in implementing dietary changes. Without personalized guidance and support, the client may struggle to navigate food options effectively and may experience difficulties in adhering to the dietary recommendations.

D. It is okay to cheat because of the medications:

Encouraging cheating or deviating from the dietary plan due to medications undermines the importance of dietary modifications in managing coronary heart disease. It is essential to emphasize the significance of following a heart-healthy diet and lifestyle, as medications alone may not be sufficient to manage the condition effectively. Providing education on medication adherence and dietary guidelines, along with ongoing support, helps reinforce the importance of consistent dietary habits in promoting cardiovascular health.

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A charge nurse is precepting a newly licensed nurse who is to administer a transfusion of packed red blood cells (PRBC) to a client who has anemia. Which of the following actions by the new nurse should cause the charge nurse to intervene in this client's care immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled for a transthoracic echocardiography (TTE). What should the nurse teach the client in anticipation of this diagnostic procedure?

Correct Answer is A

Explanation

A nurse is educating on the foods a client newly diagnosed with coronary heart disease should eat. How can the nurse best ensure the client will follow the dietary plan of care?

Correct Answer is A

Explanation

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