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 D

Explanation

A. Perform CPR for a client who is not breathing: CPR is within the scope of trained assistive personnel, but a nurse or advanced provider typically manages it in an emergency scenario.
B. Complete distal capillary refill checks for a client who has an open leg wound: Capillary refill checks require clinical assessment skills, which are outside the AP's scope of practice.
C. Determine which clients need priority medical treatment: Triage and prioritization require clinical judgment, which is the nurse's responsibility.
D. Answer questions from area residents who have health concerns: APs can answer non-clinical questions and provide basic information to area residents.

A. Place throw rugs on uncarpeted floors in the client's home. B. Ensure the client wears non-skid slippers when walking around the house. C. Encourage an annual review of the medications the client is taking. D. Install a raised toilet seat in the client's bathroom. E. Attach full-length side rails to the client's bed.

Correct Answer is ["B","C","D"]

Explanation

A. Place throw rugs on uncarpeted floors in the client's home. Throw rugs are a tripping hazard and should be removed or secured.
B. Ensure the client wears non-skid slippers when walking around the house: Non-skid slippers provide traction and reduce the risk of slipping.
C. Encourage an annual review of the medications the client is taking. Many medications can cause dizziness or sedation, increasing fall risk, so regular medication reviews are essential.
D. Install a raised toilet seat in the client's bathroom. A raised toilet seat makes it easier for older adults to use the toilet and reduces the risk of falls when standing or sitting.
E. Attach full-length side rails to the client's bed. Full-length side rails can increase the risk of injury if the client attempts to climb over them. Half-rails may be safer.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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