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. "If you are allergic to gluten you should not receive this vaccine."Gluten allergy is not a contraindication for the MMR vaccine. The vaccine does not contain gluten, and an allergy to gluten would not prevent someone from safely receiving the vaccine. However, individuals with severe allergies to neomycin or gelatin (which are components of the vaccine) should not receive it.

B. "Avoid pregnancy for at least 28 days after receiving the vaccine."The MMR vaccine contains live attenuated viruses, and there is a theoretical risk to the fetus if a woman becomes pregnant shortly after vaccination. Therefore, it is recommended that women avoid becoming pregnant for at least 28 days after receiving the MMR vaccine to reduce any potential risks.

C. "Avoid breastfeeding for 3 days after receiving the vaccine."The MMR vaccine is safe for breastfeeding mothers and does not require any interruption in breastfeeding. The vaccine viruses are not transmitted through breast milk in a way that would harm the infant.

D. "Your partner should also receive the MMR vaccine."While it is important for all individuals to be up-to-date on their vaccinations, the partner's vaccination status is unrelated to the postpartum administration of the MMR vaccine to the client. This instruction does not address a specific concern related to the postpartum period or the MMR vaccine's administration at this time.

A. Perform pelvic rocking exercises several times per day. B. Use the arms to pick up heavy items. C. Sit in a hot tub for 30 min every evening. D. Raise chairs to keep knees lower than hips.

Correct Answer is A

Explanation

Correct. Pelvic rocking exercises can help alleviate lower back pain during pregnancy by promoting movement and flexibility in the pelvic area.

Picking up heavy items with the arms might not directly address lower back pain during pregnancy.

Sitting in a hot tub for extended periods is not recommended during pregnancy due to the risk of overheating.

Raising chairs to keep knees lower than hips is a general ergonomic recommendation, but it might not directly address lower back pain.

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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.