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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Taking the vital signs of a client who is experiencing acute angina. Acute angina is a potentially unstable condition requiring assessment by a nurse.
B. Collecting a urine specimen from a client who is experiencing dysuria. APs can perform routine specimen collection tasks.
C. Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure. Only licensed nurses should provide pre-procedure instructions.
D. Reinforcing teaching with a client about stool specimen collection. Reinforcement of teaching involves assessment and evaluation, which are the nurse’s responsibilities.
Correct Answer is ["B","C","D","E"]
Explanation
A. Pain medication is administered 1 hr before a client has a dressing change. Administering pain medication before a painful procedure is appropriate and respects the client’s comfort needs.
B. The same indwelling urinary catheter is reinserted after a failed attempt. Reinserting the same catheter increases the risk of infection and violates infection control guidelines.
C. Medications scheduled four times a day are administered 2 hr after the scheduled time. This represents a medication administration error and violates safe medication administration practices.
D. Finger nail marks appear on a client's wrist after a radial pulse was taken. This may suggest physical harm, which is a violation of the client's right to safety.
E. A sublingual medication is crushed and administered through a client's gastrostomy tube. Sublingual medications are designed for absorption under the tongue and should not be altered, as doing so can affect efficacy and absorption.
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