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. Alcohol-based antiseptic rub: Alcohol-based hand rubs are ineffective against C. difficile spores.
B. Nonantimicrobial soap: Handwashing with soap and water is essential to physically remove C. difficile spores from the skin.
C. Triclosan: Triclosan is an antimicrobial agent used in some handwashes but lacks efficacy against C. difficile spores.
D. Chlorhexidine gluconate: While effective against a broad spectrum of bacteria, it does not reliably kill C. difficile spores.
Correct Answer is B
Explanation
A. "Once the form is notarized, it cannot be changed." Advance directives can be changed or revoked by the client at any time.
B. "My health care surrogate can decide my treatment if I am unable to." A healthcare surrogate is legally authorized to make decisions when the client is incapacitated.
C. "My attorney will need to notarize the document." Notarization is not typically required by an attorney; any authorized notary public can perform this task.
D. "I have to choose a member of my family to be my health care surrogate." Clients can choose any trusted individual, not necessarily a family member.
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