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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?

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

Answer and Explanation

The Correct Answer is D

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

Rationale:

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.

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Correct Answer is ["A","C","E"]

Explanation

Since the client is experiencing upper chest discomfort and coughing up sputum, it is important to assess their oxygen saturation level. This finding can provide vital information about the client's respiratory status and the adequacy of their oxygenation.

The client's report of upper chest discomfort and coughing up thick clear sputum should prompt an assessment of their respiratory rate. Abnormal respiratory rates may indicate respiratory distress or compromise, which requires immediate attention.

Assessing the client's current level of consciousness is crucial, as any sudden changes in their mental status may indicate a serious underlying issue. Since the client has a history of Parkinson's disease and reported "feeling bad," it is important to evaluate their neurological status promptly.

The other options listed (tremors, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.

A. "Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled.” B. "A nurse accidentally omitted a prescribed dressing change. C. "Prescribed dressing change was accidentally omitted during the previous shift.” D. "Incident report completed.

Correct Answer is C

Explanation

Choice A rationale:

This statement implies that the nurse attempted the dressing change but was unsuccessful. However, the information about the dressing not being soiled is irrelevant to the incident report. The key issue is the omission of the prescribed procedure.

Choice B rationale:

This statement acknowledges the omission but lacks specificity. It does not state the nature of the omission or the potential consequences, making it less informative for future prevention strategies.

Choice C rationale:

This statement clearly and concisely states the situation, indicating that the prescribed dressing change was omitted. It provides essential information for understanding what happened, allowing for appropriate investigation and preventive measures.

Choice D rationale:

This statement confirms the completion of the incident report but does not provide details about the incident itself. Without specific information about the omission, this statement is insufficient for understanding the nature of the error and implementing preventive actions.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","E"]

Explanation

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

Correct Answer is C

Explanation

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