Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

- A. This choice is incorrect because verapamil and TPN do not have a significant food and medication interaction. Verapamil is a calcium channel blocker that can lower blood pressure and heart rate, while TPN is a form of intravenous nutrition that provides calories, electrolytes, vitamins, and minerals. The nurse should monitor the client's vital signs and blood glucose levels, but there is no need to intervene to prevent an interaction.

- B. This choice is incorrect because phenytoin and milkshakes do not have a significant food and medication interaction. Phenytoin is an anticonvulsant that can decrease the absorption of some vitamins, such as folic acid and vitamin D, but milkshakes are not a major source of these nutrients. The nurse should encourage the client to eat a balanced diet and take supplements as prescribed, but there is no need to intervene to prevent an interaction.

- C. This choice is incorrect because potassium-rich foods and furosemide do not have a significant food and medication interaction. Furosemide is a loop diuretic that can cause hypokalemia, or low potassium levels, but potassium-rich foods can help prevent this complication. The nurse should monitor the client's electrolyte levels and fluid balance, but there is no need to intervene to prevent an interaction.

- D. This choice is correct because MAOIs and cheeseburgers have a significant food and medication interaction. MAOIs are antidepressants that can cause hypertensive crisis, or dangerously high blood pressure, if the client consumes foods that contain tyramine, such as aged cheeses, cured meats, fermented foods, and beer. The nurse should intervene to prevent the client from eating a cheeseburger and educate the client about avoiding tyramine-containing foods while taking MAOIs.

A. Sodium 142 mEq/L. B. Respiratory rate 22/min. C. Potassium 3.9 mEq/L. D. Heart rate 148/min.

Correct Answer is D

Explanation

Choice A rationale:

Sodium level of 142 mEq/L is within the normal range (135-145 mEq/L) for adults. However, normal ranges for children might vary slightly, but 142 mEq/L is not indicative of dehydration on its own.

Choice B rationale:

Respiratory rate of 22/min is within the normal range for a 3-year-old child (20-30 breaths/min) This rate alone does not provide evidence of dehydration.

Choice C rationale:

Potassium level of 3.9 mEq/L is within the normal range (3.5-5.1 mEq/L) for children. Like sodium, normal ranges for potassium may differ slightly in pediatric patients, but 3.9 mEq/L is not alarming on its own.

Choice D rationale:

Heart rate of 148/min is elevated for a 3-year-old child. Tachycardia is a common sign of dehydration in pediatric patients. This increased heart rate indicates the body's compensatory mechanism to maintain cardiac output in response to decreased blood volume, a typical consequence of dehydration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

Correct Answer is D

Explanation

A nurse is caring for a 3-year-old toddler who has dehydration.Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is admitting a client to the medical-surgical unit.The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

A client on an acute mental health unit states to a nurse, "Tie a bow.Row the boat.Now I know.Whoa! I see you, yo." The nurse should document that the client is exhibiting which of the following speech alterations?

A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

A nurse is caring for a client following an involuntary admission to an acute mental health facility.The client states, "I'm afraid they will give me drugs that put me to sleep." Which of the following statements should the nurse make?

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area.Which of the following interventions should the nurse include?

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?