The nurse is reviewing the client's medical record.

Procedures

Planned endoscopy at 1300.

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.

Witness the client signing a consent for transfusion.

Obtain a large bore IV catheter.

Ensure two nurses confirm the information on the blood label.

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

Explain to the client that transfusion reactions are not serious.

Answer and Explanation

Correct Answer : A,B,C

A.   Correct. The nurse should witness the client signing a consent form for blood transfusion.
Informed consent is necessary for any medical procedure.
B.   Correct. A large bore IV catheter is required for blood transfusion to ensure the smooth flow of blood and prevent clotting.
C.   Correct. Two nurses should confirm the information on the blood label, including the client's identification and the blood type, to prevent errors.
D.   Incorrect. Transfusion tubing is typically flushed with normal saline before attaching it to the patient. Flushing with dextrose 5% in water is not necessary or recommended.
E.   Incorrect. It's important for the nurse to educate the client about potential transfusion reactions, as some reactions can indeed be serious. Providing accurate information helps the client understand the importance of monitoring for any signs of a reaction.

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Correct Answer is C

Explanation

A. Incorrect. While family medical history might provide some context, physical assessment findings are more directly relevant to a referral for a physical therapist.
B. Incorrect. Medical health insurance claims are administrative and financial information, not typically included in a referral for a physical therapist.
C. Correct. Physical assessment findings, such as range of motion limitations, mobility issues, gait abnormalities, and areas of pain or discomfort, are essential for a physical therapist to develop an appropriate plan of care.
D. Incorrect. Medications taken prior to admission might have some relevance, but physical assessment findings are crucial for a physical therapist to understand the client's physical condition.

A. Cottage cheese B. Puffed rice cereal C. Tomato juice D. Bran muffin

Correct Answer is D

Explanation

A. Cottage cheese is a dairy product that is not particularly high in fiber and might not effectively help with constipation.
B. Puffed rice cereal is often low in fiber and might not be the best choice to address constipation.
C. While tomato juice can have some benefits, it is not a high-fiber choice to help alleviate constipation.
D. Correct. Bran muffins are a good source of dietary fiber, which can help promote regular bowel movements and relieve constipation.

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The nurse is reviewing the client's medical record. Procedures Planned endoscopy at 1300. 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 in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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The nurse is reviewing the client's medical record.

Procedures

Planned endoscopy at 1300.

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.