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 D
Explanation
A. Neologisms involve the creation of new, meaningless words that are not understood by others. The client is using real words, so this pattern does not reflect newly invented language.
B. Echolalia refers to the repetition of words or phrases spoken by others. The client’s speech is not repeating another person’s words but instead shows a pattern based on sound.
C. Word salad is characterized by completely disorganized, incoherent speech with no logical or grammatical connection between words. Although unusual, the client’s speech maintains structure and is linked by sound patterns rather than being entirely random.
D. Clang associations occur when speech is driven by the sound of words, such as rhyming or punning, rather than meaning. The client’s use of rhyming phrases like “bow,” “boat,” “know,” and “yo” demonstrates this pattern clearly.
Correct Answer is C
Explanation
"How does this make you feel?"
- A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
- B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
- C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
- D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.
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