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 B

Explanation

A. Incorrect. Verifying the TPN solution amount is not directly related to preparing for central venous catheter insertion.
B. Correct. Chest X-rays are typically done after central venous catheter insertion to confirm proper catheter placement.
C. Incorrect. Sims' position is not the appropriate position for central venous catheter insertion.
The Trendelenburg position is commonly used for this purpose.
D. Incorrect. Sterile technique, not clean technique, is used for changing the catheter dressing to prevent infection.

A. "I should decrease my salt intake to 2 grams per day." B. "I should exercise for 15 minutes two times per week." C. "I can have two glasses of wine with dinner." D. "I will set my blood pressure goal at 130 over 84."

Correct Answer is A

Explanation

A. Correct. Reducing salt intake is an important dietary modification for managing hypertension.
A limit of 2 grams per day is in line with recommended guidelines.
B. Incorrect. The recommended amount of exercise for managing hypertension is at least 150 minutes of moderate-intensity aerobic activity per week, not just 15 minutes twice a week.
C. Incorrect. Alcohol consumption should be limited or moderated, and the client should be cautious about alcohol interactions with blood pressure medication.
D. Incorrect. The blood pressure goal for individuals with hypertension is often set lower, around 130 over 80 or even lower, to reduce the risk of cardiovascular complications.

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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

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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.