A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?
Check the client's blood type and crossmatch it against the provider's orders.
Ask the client to state their blood type prior to beginning blood administration.
Compare information on the blood product to the informed consent form.
Verify the client and blood product information with another licensed nurse.
The Correct Answer is D
A. This is not a correct procedure for client identification, but rather for blood compatibility. The nurse should check the client's blood type and crossmatch it against the blood product label, not the provider's orders.
B. This is not a reliable method of client identification, as the client may not know or remember their blood type correctly. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.
C. This is not a relevant step for client identification, but rather for informed consent. The nurse should ensure that the client has signed an informed consent form before administering blood, but this does not verify that the blood product matches the client.
D. This is the correct procedure for client identification, as it involves two licensed nurses who independently check and confirm the client's identity and the blood product information, such as blood type, Rh factor, expiration date, and serial number.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.
B. Incorrect. Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.
C. Incorrect. A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults.
D. Incorrect. The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.
Correct Answer is D
Explanation
Choice A reason
Ensuring that the client's family supports the provider's decision for surgery is not an appropriate action. While family support is essential in the decision-making process, the primary responsibility lies with the client's health care surrogate or designated decision-maker. The family's support is not a substitute for obtaining informed consent from the designated decision-maker.
Choice B reason
Sending the unsigned informed consent form to the facility's risk manager is not appropriate action. The nurse should not send an unsigned informed consent form to the facility's risk manager. Unsigned consent forms do not have any legal significance or validity. The nurse should work with the health care surrogate to ensure that the consent form is appropriately completed and signed.
Choice C reason
Determining if the procedure is medically necessary for the client is not appropriate action. While the medical necessity of the procedure is important, the decision about the procedure's necessity should be made by the medical team and discussed with the health care surrogate. The nurse's role is to facilitate communication and ensure that the surrogate is informed and involved in the decision-making process.
Choice D reason
When a client is in a coma and unable to provide informed consent, the health care surrogate or designated decision-maker becomes responsible for making medical decisions on behalf of the client. It is essential for the nurse to ensure that the health care surrogate is aware of the situation, understands the risks and benefits of the surgical procedure, and has provided informed consent on behalf of the client.
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