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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

Explanation

The adolescent has not voided in 4 hr.

Rationale:

A. The nurse should not address the parents' concerns and provide education and support, but refer the concerns to the provider to address the concerns about the surgical procedure.
B. The adolescent's blood pressure is 131/89 mm Hg. This is not a correct answer because this blood pressure is within the normal range for an adolescent and does not indicate any complications or adverse effects from the injury or medication.
C. The adolescent reports severe pain. This is not a correct answer because the nurse should administer morphine as prescribed for pain relief, but this is not a priority finding that requires immediate intervention or reporting to the provider. The nurse should also monitor the adolescent's pain level and response to medication, and use nonpharmacological methods to reduce pain and anxiety.
D.Although this may raise concerns about renal injury, it is no a contraindication or cause for delay for the emergency surgical procedure.

A. "I can keep a can of concentrated formula in the refrigerator for 3 days after I open it.” B. "I can dilute the ready-to-feed formula with water when my baby wants more than 4 ounces at a feeding.” C. "I should boil tap water for 2 minutes and cool it before I mix it with the powdered formula.” D. "I will be sure that all of my bottles contain BPA.”

Correct Answer is C

Explanation

Choice A rationale:

Keeping a can of concentrated formula in the refrigerator for 3 days after opening it is not safe. Once a can of formula is opened, it should be used within 24 hours and stored in the refrigerator. After 24 hours, any leftover formula should be discarded to prevent the risk of bacterial contamination.

Choice B rationale:

Diluting ready-to-feed formula with water is incorrect. Ready-to-feed formula is already prepared and does not need to be diluted further. Adding water to ready-to-feed formula can dilute its nutritional content and may not provide the necessary nutrients for the baby.

Choice C rationale:

Boiling tap water for 2 minutes and cooling it before mixing it with powdered formula is the correct method for safe formula preparation. Boiling the water kills harmful bacteria and ensures the formula is safe for the baby to consume. It is essential to cool the boiled water before mixing it with powdered formula to reach an appropriate feeding temperature.

Choice D rationale:

Ensuring that all bottles contain BPA (bisphenol A) is not a relevant consideration for formula preparation. BPA is a chemical that was previously used in some plastics, including baby bottles, but has been banned in baby bottles and sippy cups in several countries due to its potential health risks. Most modern baby bottles are BPA-free, and this statement does not address the safe handling and preparation of formula for the baby.

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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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