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 C
Explanation
A. Tinnitus is not a common symptom of bacterial pneumonia.
B. Rhinorrhea (runny nose) is more commonly associated with viral infections, not bacterial pneumonia.
C. Malaise is a common symptom of bacterial pneumonia, as the infection causes generalized weakness and discomfort.
D. Drooling is not a common symptom of bacterial pneumonia, but it may be seen in conditions like throat infections.
Correct Answer is C
Explanation
A. A pulse rate of 100/min is within the expected range and is not an indication for concern with magnesium sulfate administration.
B. Proteinuria of 1+ indicates mild protein in the urine, which is a sign of preeclampsia, not necessarily a therapeutic effect of magnesium sulfate.
C. Monitoring deep tendon reflexes for signs of magnesium sulfate toxicity (e.g., loss of reflexes) is essential.
D. Urine output of 20 mL/hr is below the expected output and may indicate toxicity or kidney issues, so it should be carefully monitored.
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