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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?

A.

Check the client's blood type and crossmatch it against the provider's orders

B.

Ask the client to state their blood type prior to beginning blood administration

C.

Compare information on the blood product to the informed consent form

D.

Verify the client and blood product information with another licensed nurse

Answer and Explanation

The Correct Answer is D

Verify the client and blood product information with another licensed nurse.

Rationale:

  1. 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.
  2. 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.
  3. 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.
  4. 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.


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Related Questions

Correct Answer is C

Explanation

Choice A rationale:

Limiting fluid intake to 1 liter per day can lead to dehydration and other health complications. It is important for the client to maintain adequate hydration, especially postpartum. This option is incorrect and potentially harmful.

Choice B rationale:

Manual expression of milk can help relieve engorgement without stimulating further milk production. This method allows the client to express milk as needed. However, it can be done even before engorgment occurs

Choice C rationale:

Wearing a snug-fitting bra can provide support and comfort.

Choice D rationale:

Applying moist heat to the breasts can stimulate milk production and relieve engorgement. However, in this case, the client wants to suppress lactation. Therefore, this option is not appropriate and may have the opposite effect of increasing milk production.

Correct Answer is B

Explanation

A. "Limit each of the client's visitors to 2 hr per day."
This is incorrect. While visitors should have their exposure limited, the recommended duration is typically much shorter (around 30 minutes to 1 hour), not 2 hours. This is to reduce radiation exposure.

B. "Instruct visitors to stay 1 m (3.3 feet) away from the client."
This is correct. For clients undergoing brachytherapy with a low-dose radiation implant, visitors should maintain a safe distance, usually at least 6 feet (1.8 meters), but some guidelines may state a minimum of 3.3 feet (1 meter) for safety, depending on the specific radiation dose and facility protocols.

C. "Attach a dosimeter to the client's gown."
This is incorrect. Dosimeters are generally worn by healthcare providers, not the patient. The primary purpose is to measure the radiation exposure of healthcare workers, not the patient.

D. "Strain the client's urine."
This is incorrect. Straining urine is not necessary for a patient undergoing brachytherapy. However, it may be important to monitor the urine for signs of radiation leakage, but straining is not a routine part of care.

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