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. Perform a specific nursing task for a group of clients: This approach aligns more with functional nursing, not total patient care.
B. Provide complete care for a caseload of clients: In total patient care, the nurse is responsible for all aspects of care for a specific group of clients during their shift.
C. Receive cross-training in multiple departments: Cross-training is related to float pool or department-specific training, not the care delivery method.
D. Delegate low-skilled tasks to assistive personnel: While delegation may occasionally occur, the focus in total patient care is on the nurse providing direct care.
Correct Answer is B
Explanation
A. "The client is 2 hours postoperative following a cholecystectomy." This belongs in the "B" (Background) section since it provides historical or procedural information.
B. "The client rates her pain at a 3 on a 0 to 10 pain rating scale." This is part of the "A" (Assessment) portion as it involves the nurse's evaluation of the client's current condition.
C. "The client has type 2 diabetes mellitus." This is background information relevant to the client's medical history and should be included in the "B" section.
D. "The client should wear compression stockings." This is part of the "R" (Recommendation) section as it involves future care instructions.
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