A nurse is reinforcing client teaching about preventing stress injuries. Which of the following statements by the client indicates an understanding of teaching?

Rationale

• Ensure the transfusion tubing is flushed with dextrose 5% in water: Flushing with D5W can cause hemolysis due to the hypotonicity and sugar content, leading to clumping or damage to red blood cells. Normal saline is the only acceptable fluid for flushing or administering with blood products to maintain cell integrity and avoid adverse reactions.

• Obtain a large-bore IV catheter: A large-bore catheter, typically 18–20 gauge, is necessary to allow rapid infusion of blood and reduce the risk of hemolysis. It also minimizes resistance and facilitates effective delivery during emergencies like hypovolemic shock from GI bleeding.

• Witness the client signing a consent for transfusion: Informed consent is a legal and ethical requirement prior to initiating a transfusion. The nurse must ensure that the client understands the purpose, benefits, and risks of the procedure, and the nurse may witness the client’s signature.

• Ensure two nurses confirm the information on the blood label: Verifying the client's identity and blood product information by two licensed personnel prevents transfusion errors, such as ABO incompatibility. This is a critical safety measure and a standard facility protocol before starting the transfusion.

• Explain to the client that transfusion reactions are not serious: Minimizing the risks of transfusion reactions is misleading and unsafe. Some reactions can be life-threatening, such as hemolytic or anaphylactic reactions. The nurse should provide accurate education about potential signs and encourage prompt reporting.

Rationale:

A. Plan a time at the end of the shift to document nursing interventions: Delaying documentation until the end of the shift risks forgetting important details and compromises accuracy. Best practice is to document interventions and observations as close to the time of care as possible to ensure timely, complete records.

B. Delegate collection of vital signs to the assistive personnel on the team: Delegating routine tasks like vital sign collection allows the nurse to focus on complex responsibilities requiring clinical judgment. This supports time efficiency while ensuring client care needs are still met promptly.

C. Make a priority to-do list at the beginning of the shift: Creating a task list based on client acuity and scheduled interventions helps the nurse remain focused and organized. Prioritizing tasks early supports decision-making and improves workflow throughout the shift.

D. Keep track of how long it takes to complete certain tasks: Monitoring time spent on different tasks helps identify inefficiencies and allows the nurse to adjust workflow. This self-awareness supports better time management in future shifts.

E. Complete activities with one client before moving to another client: Focusing on one client at a time may lead to inefficiencies and delayed care for other clients. Nurses should cluster care and prioritize based on client needs, rather than adhering rigidly to completing all care for one client before moving on.