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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Applying the restraint over the client's gown: Restraints should be applied over clothing or a gown to prevent skin irritation and ensure comfort.
B. Using a quick-release knot to secure the restraint: A quick-release knot is the recommended method for securing restraints to ensure they can be removed quickly in an emergency.
C. Placing the restraint across the client's chest: Belt restraints should be placed around the waist, not the chest, as chest placement can impair breathing.
D. Tying the restraint to the bed frame: Restraints should be tied to the bed frame (not the side rails) to prevent injury during bed movement.

A. "It sounds like you have concerns about the procedure." B. "Why have you decided not to have the procedure?" C. "Don't worry. You will adjust to the colostomy quickly." D. "Do you think that's the right decision for you and your family?"

Correct Answer is A

Explanation

A. "It sounds like you have concerns about the procedure." This therapeutic response acknowledges the client's feelings and encourages further discussion without judgment.
B. "Why have you decided not to have the procedure?" Asking "why" can make the client feel defensive and may hinder communication.
C. "Don't worry. You will adjust to the colostomy quickly." This statement dismisses the client's concerns and does not foster effective communication.
D. "Do you think that's the right decision for you and your family?" This question may pressure the client instead of promoting open dialogue.

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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

A nurse is observing an assistive personnel (AP) apply a belt restraint on a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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