A nurse receives a change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?

Obtain informed consent from the client for the blood transfusion.

Delegate the client's care to an RN.

Access the nursing information system for guidelines about blood transfusions.

Inform the charge nurse of the need to reassign the client's care.

Answer and Explanation

The Correct Answer is C

A.   Obtain informed consent from the client for the blood transfusion: Verifying that informed consent is obtained is essential, but obtaining consent is the provider's responsibility. The nurse's role is to ensure the consent has been signed and documented.
B.   Delegate the client's care to an RN: If the nurse receiving the shift report is already an RN, delegating the care to another RN is unnecessary unless there are specific time constraints or workload considerations.
C.   Access the nursing information system for guidelines about blood transfusions: This is an appropriate action to ensure that institutional policies and guidelines are followed regarding blood administration, which may include steps for patient identification, infusion rates, and monitoring for reactions.
D.   Inform the charge nurse of the need to reassign the client's care: This is typically not necessary unless the assigned nurse lacks the competency to administer blood products or has competing responsibilities that prevent safe monitoring of the transfusion.

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Correct Answer is B

Explanation

A. Close the door to the client's room: This helps contain the fire and prevents smoke from spreading, but it should not be the immediate action after client removal.
B. Activate the alarm outside the client's room: Activating the alarm is critical after ensuring the client's safety, as it alerts the facility to the emergency and mobilizes response teams.
C. Use a Class A fire extinguisher to contain the fire: The type of extinguisher used depends on the fire classification. Attempting to extinguish a fire should occur only after the alarm is activated.
D. Turn off electrical equipment in the client's room: While turning off electrical equipment can reduce fire hazards, it is not the next priority after removing the client.

A. Examine personal values. B. Agree on a desired outcome. C. Create a plan of action. D. Collect the relevant facts.

Correct Answer is D

Explanation

A. Examine personal values: Understanding personal biases is important, but this is not the initial step in ethical decision-making.
B. Agree on a desired outcome: Reaching a consensus is essential but should come after gathering the necessary information.
C. Create a plan of action: Developing a plan is premature without gathering facts and understanding the situation.
D. Collect the relevant facts: Gathering all relevant information is the first step to understanding the ethical dilemma and determining an appropriate response.

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A nurse receives a change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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