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.

Answer and Explanation

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

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Correct Answer is ["B","C","E","F","H"]

Explanation

Findings Requiring Immediate Follow-Up:

B. Hemoglobin and Hematocrit:
The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly lower than normal (14-18 g/dL for hemoglobin and 40-52% for hematocrit). This is indicative of anemia, which could be due to chronic blood loss, potentially from a gastrointestinal source (given the history of dark, tarry stool). Anemia can lead to symptoms such as weakness, dizziness, and fatigue, and if severe, it could lead to hypovolemic shock.
C. Stool results:
The hemoccult stool test is positive, indicating gastrointestinal bleeding, likely from an upper GI source (e.g., ulcers or gastritis). Combined with the client's symptoms of gnawing abdominal pain, a burning sensation radiating to the back, and a history of dark, tarry stools (which suggests melena), this is concerning for a peptic ulcer disease (PUD) or even a gastric ulcer. This finding warrants immediate follow-up to evaluate the cause and assess for complications such as active bleeding or perforation.
E. Blood Pressure:
The client’s blood pressure is 90/50 mm Hg, which is hypotensive and likely a sign of hypovolemia due to blood loss (from the GI bleeding indicated by the positive hemoccult test). Hypotension is a concerning finding, especially in a client with anemia and symptoms of abdominal distress. Immediate intervention is needed to address the blood pressure and prevent further complications, such as shock.
F. Temperature:
The client’s temperature is 37.5°C (99.5°F), which is slightly elevated (normal is typically 36.1-37.2°C or 97°F-99°F). While not dramatically high, a low-grade fever could suggest an infection (e.g., due to H. pylori, which is positive in this client, or an associated gastric infection or inflammation). In this case, it could indicate a need for monitoring, as infections can exacerbate symptoms and complications, particularly in the setting of a GI ulcer or bleeding.
H. Heart Rate:
The client's heart rate is elevated at 118 beats per minute (tachycardia). Tachycardia in this setting could be a compensatory mechanism for hypovolemia due to the blood loss suggested by the low hemoglobin/hematocrit and positive stool test. The elevated heart rate could also be a sign of pain, anxiety, or systemic response to the GI distress. Regardless, tachycardia is a significant finding in the context of hypotension and anemia and requires immediate follow-up to prevent cardiovascular complications.

Findings That Do Not Require Immediate Follow-Up:
A. Current Medications:
The client is taking Ibuprofen, which is a nonsteroidal anti-inflammatory drug (NSAID). While NSAIDs can cause gastrointestinal irritation and increase the risk of bleeding (particularly in the presence of ulcers), the client’s current medications do not require immediate follow-up as a standalone issue. However, if a diagnosis of ulcer or gastrointestinal bleeding is confirmed, the use of NSAIDs should be discontinued.
D. WBC Count:
The client's WBC count is 6,700/mm³, which is within the normal range (5,000-10,000/mm³). This does not indicate infection or significant inflammation. Given the context of the client’s symptoms and lab results, there is no immediate concern with the WBC count at this time.
G. Respiratory Rate:
The client’s respiratory rate is 18/min, which is within the normal range (12-20 breaths per minute for adults). There is no indication of respiratory distress or abnormal breathing patterns in this patient, so no immediate follow-up is required in this area.

A. Wear clean cotton socks every day. B. Round the edges of toenails when trimming C. Soak feet twice daily. D. Use moisturizing lotion between the toes.

Correct Answer is A

Explanation

A. Wearing clean cotton socks helps to reduce the risk of infection and provides a comfortable fit for those with diabetes.
B. Toenails should be trimmed straight across to prevent ingrown nails, not rounded at the edges.
C. Soaking feet daily can lead to skin breakdown, particularly for diabetics with neuropathy.
D. Moisturizing lotion should be applied to the feet, but not between the toes, to avoid moisture buildup and fungal infections.

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["B","C","E","F","H"]

Explanation

A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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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.