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. Assessing for the characteristic erythema migrans (bullseye rash) and other manifestations of Lyme disease is important for early detection and treatment.
B. Lyme disease is not contagious and does not require isolation or restrictions on sharing personal belongings.
C. Antitoxin is not used for Lyme disease; antibiotics are the primary treatment.
D. While Lyme disease should be reported, it is not a mandatory report to the state health department unless there is an outbreak or specific reporting requirements.
Correct Answer is B
Explanation
A. The nurse should not make a judgment about the client’s benefit from reviewing their notes; the
client has the right to access their records.
B. Psychotherapy notes are protected and are not included in the general medical record. The nurse should inform the client of this policy.
C. Asking if the client is happy with treatment could be perceived as dismissive and irrelevant to the
client’s right to access their records.
D. The nurse should not question the client’s motivation but rather provide accurate information about the process for obtaining their records.
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