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.

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Correct Answer is A

Explanation

A. "I will get you information about some head-covering options." This response is supportive and addresses the client's concerns about hair loss in a practical way. Providing information about head coverings, such as hats, scarves, or wigs, can help the client feel more prepared and empowered to manage this aspect of their treatment.
B. "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing the client's concerns may make them feel invalidated. Hair loss can be a significant emotional issue for many clients undergoing chemotherapy, and it’s important to address their feelings and provide support.
C. "Let's discuss this when we have more time." Postponing the conversation may leave the client feeling anxious or unsupported. Clients may need immediate reassurance and resources regarding their concerns, so it is essential to address it in a timely manner.
D. "I can't imagine how difficult it would be to lose my hair." Expressing empathy is important, but shifting the focus to the nurse's feelings rather than addressing the client's concerns is not helpful. It is more beneficial to provide practical support and resources to help the client cope with potential hair loss.

A. Believes that his brother's death will be reversible B. Believes his bad behavior is causing his brother's death C. Alienates himself from his peers D. Regresses to an earlier developmental level

Correct Answer is B

Explanation

A. Believes that his brother's death will be reversible. This response is more typical of preschool-aged children (ages 3 to 5), who often perceive death as temporary or reversible, similar to sleep or separation. School-age children, however, begin to understand the finality of death, though they may still struggle with its implications.
B. Believes his bad behavior is causing his brother's death. School-age children (ages 6 to 12) often engage in magical thinking and may believe that their actions, thoughts, or behaviors are responsible for events, including illness and death. They may feel guilt and self-blame, thinking that past misbehavior contributed to their sibling's condition. Providing reassurance and education about the medical causes of the illness can help alleviate these feelings.
C. Alienates himself from his peers. While social withdrawal can occur in grieving children, school-age children typically seek peer support and may use friendships as a coping mechanism. Alienation is more commonly seen in adolescents, who might isolate themselves due to difficulty expressing emotions or fear of burdening others.
D. Regresses to an earlier developmental level. Regression, such as bedwetting, clinging behavior, or baby talk, is more commonly seen in younger children, particularly toddlers and preschoolers, when they experience stress or grief. School-age children are more likely to express distress through guilt, sadness, or behavioral changes rather than regression.

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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.

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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.