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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While monitoring oxygen saturation is important, ensuring an open airway takes priority.
B. Administering oxygen is important, but ensuring an open airway is the initial priority.
C. Checking the pulse rate is important, but ensuring an open airway is the initial priority.
D. Correct. Establishing a patent airway is the most critical action for a client with compromised breathing and cyanosis.
Correct Answer is A
Explanation
A. Correct. A warming sensation or a feeling of warmth throughout the body is a common sensation experienced by patients during an intravenous pyelogram due to the contrast dye used.
B. Limiting fluid intake is not typically necessary after an intravenous pyelogram; in fact, increased fluid intake is often recommended to help flush the dye from the body.
C. A signed consent form is usually required for invasive procedures like an intravenous pyelogram.
D. Eating or drinking before the procedure might interfere with the test results, so it is generally not allowed.
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