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 A
Explanation
A. Correct. Observing the client during and after meals is a priority because clients with bulimia nervosa often engage in episodes of binge eating followed by purging behaviors. Monitoring the client's behavior during meals and immediately after can help assess for potential purging behaviors.
B. Incorrect. While involving the client in meal planning might be helpful, it is not the first action to address potential purging behaviors.
C. Incorrect. Instructing the client about effective coping strategies is important, but observing for potential purging behaviors is the initial action to address the client's immediate safety.
D. Incorrect. Referring the client to a support group is beneficial, but it is not the first action to address the client's immediate risk of purging behaviors.
Correct Answer is B
Explanation
A. Incorrect. No sounds heard after listening for 3 to 5 minutes would be considered absent bowel sounds.
B. Correct. Hyperactive bowel sounds are louder and more frequent than normal and can indicate increased bowel motility. They can also be present in early bowel obstructions due to increased peristalsis.
C. Incorrect. Soft sounds at a rate of 1/min are within the range of normal bowel sounds.
D. Incorrect. Decreased motility would result in hypoactive bowel sounds, not hyperactive.
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