A nurse receives 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?
Inform the charge nurse of the need to reassign the client's care.
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.
The Correct Answer is B
A. Informing the charge nurse of the need to reassign the client’s care is unnecessary unless the nurse is unable to provide safe and competent care for the transfusion.
B. Obtaining informed consent is essential before a blood transfusion to ensure the client is aware of the procedure's purpose, benefits, and potential risks.
C. Delegating the client's care to another RN may be appropriate if the nurse lacks competence with transfusions, but obtaining consent is a priority.
D. Accessing the nursing information system for transfusion guidelines is helpful, but obtaining consent takes precedence before proceeding with the transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Smoke alarm batteries should be changed at least once a year, not every 2 years, so this statement reflects a misunderstanding of fire safety recommendations.
B. Spraying the extinguisher from side to side at the base of the fire is the correct technique for using a fire extinguisher, indicating the client understands proper fire safety.
C. Attempting to extinguish a fire before calling the fire department can be dangerous; the client should call for help first if the fire is large or spreading.
D. A Class A extinguisher is suitable for ordinary combustibles like wood and paper, but for electrical fires, a Class C extinguisher should be used, indicating a misunderstanding of fire extinguisher types.
Correct Answer is A
Explanation
A. Obtaining the client's capillary blood glucose level is the first action because it determines the appropriate timing and dosage of insulin administration, ensuring safe and effective diabetes management.
B. Administering prescribed insulin should occur after assessing the client's blood glucose level to avoid the risk of hypoglycemia or hyperglycemia.
C. Providing the client's breakfast is important but should only occur after assessing blood glucose and administering insulin as needed to maintain stable glucose levels.
D. Checking the calibration of the glucometer is essential for accurate readings but does not directly address the immediate need to assess the client's glucose level.
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