The nurse is reviewing the client's medical record.

Exhibits

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

Obtain a large-bore IV catheter.

Explain to the client that transfusion reactions are not serious.

Ensure two nurses confirm the information on the blood label.

Ensure the transfusion tubing is flushed with dextrose 5% in water.

Witness the client signing consent for transfusion.

Answer and Explanation

Correct Answer : A,C,E

A. Obtain a large-bore IV catheter. A large-bore IV catheter (18-gauge or larger) is necessary for blood transfusion to allow for rapid administration and reduce the risk of hemolysis. The provider has already prescribed this intervention.
B. Explain to the client that transfusion reactions are not serious. This statement is inaccurate and misleading. While many transfusion reactions are mild, some can be life-threatening, such as hemolytic reactions or anaphylaxis. The nurse should educate the client about signs and symptoms of a transfusion reaction and instruct them to report any discomfort or unusual sensations immediately.
C. Ensure two nurses confirm the information on the blood label. Before administering blood, two nurses must verify the blood product against the client's identification band, medical record, and blood bank documentation to prevent transfusion errors.
D. Ensure the transfusion tubing is flushed with dextrose 5% in water. Blood products should only be administered with normal saline (0.9% sodium chloride) because dextrose-containing solutions can cause red blood cell hemolysis. The nurse should ensure the IV tubing is primed with normal saline before starting the transfusion.
E. Witness the client signing consent for transfusion. Informed consent is required before administering a blood transfusion. While obtaining consent is the provider’s responsibility, the nurse can witness the signing and ensure that the client understands the procedure.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["0.25"]

Explanation

Volume = Desired Dose / Available Concentration

Desired: 0.5 mg

Available: 2 mg/mL

Calculation:

Volume = 0.5 mg / 2 mg/mL

Volume = 0.25 mL

Answer: 0.25 mL

A. The client is assigned to a room with negative airflow. B. The client has artificial flowers in the room. C. The client's meal tray contains hard boiled eggs. D. The client's meal tray includes ice cream with fresh fruit.

Correct Answer is D

Explanation

A. The client is assigned to a room with negative airflow. Negative airflow rooms are used for airborne infection isolation, such as for tuberculosis, not for neutropenic clients. Neutropenic clients should be placed in a positive airflow room to reduce exposure to airborne pathogens.
B. The client has artificial flowers in the room. Fresh flowers and potted plants can harbor bacteria and fungi, increasing the risk of infection. However, artificial flowers do not pose this risk and are generally considered safe.
C. The client's meal tray contains hard-boiled eggs. Fully cooked eggs are safe for neutropenic clients. Raw or undercooked eggs, such as those in soft-boiled or poached form, should be avoided due to the risk of bacterial contamination.
D. The client's meal tray includes ice cream with fresh fruit. Fresh fruit can harbor bacteria and fungi that pose a risk of infection for neutropenic clients. Unless thoroughly washed and peeled, raw fruits and vegetables should be avoided to minimize the risk of exposure to harmful pathogens.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is reviewing the client's medical record. Exhibits The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.25"]

Explanation

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

Correct Answer is D

Explanation

A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for this client?

A nurse is caring for a client who is at 14 weeks of gestation. Which of the following statements should the nurse identify as the client being emotionally prepared for pregnancy?

A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make?

A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is assisting with the care of a client who is admitted to the medical-surgical unit. Exhibits The nurse is reviewing the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

The nurse is preparing the client for discharge. Exhibits Which of the following statements indicate the client understands the discharge teaching? Select the 3 client statements that indicate an understanding of the teaching.

The nurse is obtaining the client's vital signs prior to an endoscopy. Exhibits Complete the following sentence by using the list of options. The nurse should first anticipate the need to dropdownand thendropdown

The nurse is reviewing the client's medical record.

Exhibits

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.