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. Lightheadedness upon standing, also known as orthostatic hypotension, can be a common side effect of ACE inhibitors. Advising the client to sit down when experiencing lightheadedness will help prevent falls.
B. Incorrect. Discontinuing the medication without consulting a healthcare provider is not appropriate. Lightheadedness can be managed with strategies like changing positions slowly.
C. Incorrect. Restricting fluid intake is not necessary unless advised by a healthcare provider.
Adequate hydration is important, especially with the use of certain medications.
D. Incorrect. While potassium supplements might be prescribed in some cases with ACE inhibitors, the primary concern in this situation is addressing orthostatic hypotension.
Correct Answer is B
Explanation
Protein is essential for wound healing as it plays a crucial role in tissue repair and regeneration. It provides the building blocks for new tissue formation and helps in the synthesis of collagen, which is necessary for wound healing. Adequate protein intake promotes wound healing by supporting the growth of new cells, enhancing immune function, and aiding in the formation of new blood vessels.
Calcium is important for bone health but does not directly impact wound healing. However, a balanced diet that includes sources of calcium is generally recommended for overall health. Vitamin D plays a role in bone health and has some influence on immune function and wound healing. However, the primary focus in this scenario should be on protein intake.
Fats, specifically essential fatty acids, are necessary for overall health and immune function. However, increasing fats in the diet may not directly impact wound healing. It is important to consume a balanced diet that includes healthy fats, but the emphasis for wound healing is on protein intake.
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