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 A
Explanation
A. Continuous monitoring of the respiratory status is essential in a child with epiglottitis because the condition can lead to sudden airway obstruction.
B. Suctioning the oropharynx could trigger laryngospasm and worsen airway obstruction.
C. While frequent swallowing may indicate a need for airway assessment, it is not the primary intervention for epiglottitis.
D. Pancreatic enzymes are not relevant for the management of epiglottitis.
Correct Answer is C
Explanation
A. Hand washing for at least 20 seconds with warm water and soap is recommended to prevent infection, not just 10 seconds.
B. Pregnant women should avoid cleaning the cat's litter box due to the risk of toxoplasmosis.
C. Chickenpox is contagious until all lesions have crusted, so visiting a person with chickenpox is only safe 5 days after the lesions crust over.
D. Antibiotics are not effective for viral infections and should not be taken unless prescribed for a bacterial infection.
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