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 B
Explanation
A. While progress notes are important, they do not necessarily promote communication among the entire team.
B. Regular interdisciplinary team meetings ensure that all staff are updated on the client's needs, fostering coordinated care.
C. Swallowing precautions should be communicated to the staff but are not directly related to communication about expressive aphasia or hemiparesis.
D. Noting changes in the treatment plan is important but does not specifically promote communication about the client’s condition across the team.
Correct Answer is D
Explanation
A. The client should be advised to limit the use of the affected hand, but complete rest for 4 to 6 weeks is often too long unless otherwise directed by the surgeon.
B. Ice, not heat, is recommended for pain and swelling in the first 24 hours post-surgery. Heat can exacerbate swelling.
C. Numbness and tingling should improve after surgery and not persist. If they do, it could indicate complications such as nerve damage.
D. Elevating the hand above the level of the heart helps reduce swelling and aids in the healing process after carpal tunnel surgery.
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