Exhibits
The nurse reviews the entries in the medical record.
The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.
Insert a large-bore IV catheter.
Witness the client signing a consent for transfusion.
Flush the transfusion tubing with dextrose 5% in water.
Explain to the client that transfusion reactions are not serious.
Have a second nurse confirm the information on the blood label.
Correct Answer : A,B,E
Correct actions;
A. A large-bore IV catheter is recommended for blood transfusions because it allows for faster and more efficient administration of the blood product. Blood transfusions require proper blood flow to prevent damage to the blood cells, and a larger catheter (usually 18 or 20 gauge) ensures this. A smaller catheter may increase the risk of hemolysis (destruction of red blood cells) or slower transfusion rates, which is not ideal in an emergency situation.
B. It is mandatory to obtain informed consent before any transfusion procedure. The nurse is required to witness the client’s signature on the consent form, ensuring that the client understands the procedure, risks, and benefits. The client’s statement of concern ("I'm really scared...") emphasizes the importance of having a thorough discussion and ensuring they understand what is happening.
E. Two nurses must independently verify the blood product details (such as the blood type and matching the client’s identification) before the transfusion begins. This double-checking procedure is a safety protocol to prevent transfusion errors, such as administering the wrong blood type, which can lead to severe reactions and complications.
Incorrect actions:
C. Dextrose solutions (D5W) should not be used to flush blood transfusion tubing. This is because dextrose solutions can cause hemolysis (destruction of red blood cells) when mixed with blood. The correct solution to flush blood transfusion lines is normal saline (0.9% sodium chloride), as it is compatible with blood products and helps prevent damage to the red blood cells.
D. Transfusion reactions, although rare, can be serious and even life-threatening. It is important for the nurse to provide accurate and clear information about potential transfusion reactions (e.g., allergic reactions, fever, hemolytic reactions, anaphylaxis) and to educate the client on what to expect
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Crusting of exudate is typical during wound healing and does not require immediate reporting unless other complications arise.
B. Mild swelling is expected, but it should be monitored closely.
C. Pink-tinged coloration is a normal part of healing and does not require reporting unless the incision shows signs of infection or other complications.
D. Partial separation of the incision may indicate a risk for wound dehiscence, which requires immediate provider attention.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
After notifying the provider, the nurse should first administer oxygen at 2 L/min via nasal cannula and then administer sublingual nitroglycerin
Rationale
Administer oxygen at 2 L/min via nasal cannula
The client is experiencing shortness of breath and chest pain with a decrease in oxygen saturation (92%), which is a concern, indicating that the client may be experiencing an acute cardiovascular event such as a myocardial infarction (MI). Administering oxygen helps to increase the oxygen supply to the heart and other vital organs.
Administer sublingual nitroglycerin
Nitroglycerin is a vasodilator that can help relieve chest pain associated with conditions like angina or myocardial infarction by increasing blood flow to the heart and reducing myocardial oxygen demand. The client’s pain level has increased to 7/10 on the pain scale, which suggests the chest pain may be related to an acute cardiac event.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.