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 B
Explanation
- A. Incorrect. Withholding pain medications for 24 hr after the old patch is removed is a harmful action that could cause severe withdrawal symptoms and uncontrolled pain for the client. The nurse should respect the client's right to refuse treatment and explore the reasons for their decision.
- B. Correct. Asking another nurse to witness the disposal of the new patch is a safe and legal action that follows the policies and procedures for handling controlled substances. The nurse should document the disposal of the new patch and report it to the appropriate authority.
- C. Incorrect. Sealing the patches in a plastic bag and placing them in the client's trash basket is an unsafe and illegal action that could lead to diversion, misuse, or accidental exposure of fentanyl to others. The nurse should dispose of the patches in a secure and designated container that prevents access by unauthorized persons.
- D. Incorrect. Sticking the two patches to each other and placing them in the sharps bin is an unsafe and improper action that could cause contamination, injury, or infection to others who handle or dispose of sharps waste. The nurse should dispose of the patches separately and carefully, avoiding contact with their adhesive surfaces.
Correct Answer is B
Explanation
A. Hypoxemia is a condition of low oxygen levels in the blood. PEEP can actually improve oxygenation by preventing alveolar collapse and increasing functional residual capacity.
B. Tension pneumothorax is a life-threatening condition of air accumulation in the pleural space that causes increased intrathoracic pressure and compresses the lungs, heart, and great vessels. PEEP can increase the risk of tension pneumothorax by creating excessive positive pressure in the airways and alveoli.
C. Malignant hypertension is a severe form of high blood pressure that can cause organ damage and stroke. PEEP can cause a transient increase in blood pressure due to increased intrathoracic pressure, but it does not cause malignant hypertension.
D. Atelectasis is a condition of partial or complete lung collapse due to alveolar collapse or obstruction. PEEP can prevent or treat atelectasis by maintaining positive pressure in the airways and alveoli.
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