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 C
Explanation
A. Incorrect. Elevating the arm might help reduce edema, but the priority is to stop the infusion to prevent further infiltration.
B. Incorrect. While documenting the infiltration is important, immediate action should be taken to stop the infusion to prevent further complications.
C. Correct. The nurse's first action should be to stop the infusion to prevent the continuation of fluid infiltration and potential complications.
D. Incorrect. Applying a warm compress might help with comfort, but stopping the infusion is the priority to prevent further infiltration.
Correct Answer is D
Explanation
The correct answer is choiced. "Soiled dressings should be placed in a biohazard trash receptacle.".
Choice A rationale:
For a client who has Clostridium difficile, hand hygiene should be performed with soap and water, not an alcohol-based rub, as alcohol does not effectively kill C. difficile spores.
Choice B rationale:
Droplet precautions typically require wearing a mask, not necessarily a gown and gloves. Gown and gloves are more commonly associated with contact precautions.
Choice C rationale:
Following a blood spill, a bleach solution with a ratio of 1 to 10 is recommended, not 1 to 20. This higher concentration ensures effective disinfection.
Choice D rationale:
Placing soiled dressings in a biohazard trash receptacle is correct. This prevents the spread of infection and ensures proper disposal of contaminated materials.
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