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.
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Related Questions
Correct Answer is D
Explanation
A. Contacting the provider for instructions could delay immediate resuscitative efforts, which are required in the absence of a DNR order.
B. Consulting with the client’s family may not be effective in an emergency, as the living will is a legal document, and family members cannot override it without a DNR order.
C. Complying with the living will and letting the client expire naturally would be inappropriate without a formal DNR order in place.
D. Calling a code is the correct action because, legally, resuscitative efforts must be initiated in the absence of a written DNR order from the provider, despite the existence of a living will.
Correct Answer is A
Explanation
A. Not providing an interpreter for a client who speaks a different language may violate the client's right to understand their care, leading to potential legal issues regarding informed consent and patient safety.
B. A provider speaking to a client alone about suspected partner violence is appropriate as it ensures the client's privacy and safety during a sensitive discussion.
C. Prescribing a kosher meal tray for a client who practices the Orthodox Jewish faith is respectful and meets the dietary needs of the client, which is not a legal issue.
D. A client requesting that a nurse provide information to their partner is not inherently a legal issue, but the nurse must ensure that the client has consented to share their information to protect confidentiality.
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