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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Irritability.
The rationale for each choice is as follows:
- A. Irritability: Correct. Irritability is one of the signs of hypoglycemia, which occurs when blood glucose levels fall below 70 mg/dL (3.9 mmol/L). Other signs include shakiness, sweating, hunger, headache, confusion, and blurred vision.
- B. Increased urination: Incorrect. Increased urination is one of the signs of hyperglycemia, which occurs when blood glucose levels rise above 180 mg/dL (10 mmol/L). Other signs include thirst, dry mouth, fatigue, nausea, and fruity breath odor.
- C. Vomiting: Incorrect. Vomiting is not a specific sign of hypoglycemia or hyperglycemia, but it can occur as a complication of either condition if left untreated or poorly managed.
- D.Facial flushing: Incorrect. Facial flushing is not a sign of hypoglycemia or hyperglycemia, but it can occur as a side effect of some medications used to treat diabetes, such as niacin or rosiglitazone.
Correct Answer is C
Explanation
Choice A rationale:
Massaging the legs before applying the stockings is not advisable. Vigorous massage can dislodge clots in patients with DVT, leading to serious complications like pulmonary embolism. It is essential to handle the legs gently and follow the proper procedure for applying antiembolitic stockings.
Choice B rationale:
Folding the stockings at the top if they are too long is not recommended. Altering the stockings in this way can create uneven pressure, reducing their effectiveness in preventing DVT. It is crucial to choose the correct size of stockings to ensure proper compression and prevention of complications.
Choice C rationale:
Measuring the legs with a tape measure to determine the stocking size is the correct action. Proper sizing is essential to ensure the stockings fit the patient correctly and provide the appropriate level of compression. Ill-fitting stockings can be ineffective and may even cause harm, such as skin abrasions or impeded circulation.
Choice D rationale:
Removing the stockings every 24 hours is unnecessary unless there is a specific medical indication to do so. Continuous wear of antiembolitic stockings is generally recommended to provide consistent compression and prevent deep-vein thrombosis (DVT)
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