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. This instruction helps ensure proper identification of the newborn, reducing the risk of mix-ups.
B. Incorrect. While verifying credentials is important, this action might not be feasible for every nurse and situation.
C. Incorrect. Leaving the newborn unattended is not a safe practice.
D. Incorrect. Carrying the newborn to the nursery might expose the newborn to unnecessary risks and separation.
Correct Answer is C
Explanation
The client's symptoms of feeling dizzy, having a racing heart, and becoming pale while lying on their back may indicate supine hypotensive syndrome. This condition can occur during pregnancy when the weight of the uterus compresses the inferior vena cava, reducing blood flow to the heart and causing a drop in blood pressure.
Positioning the client on their left side helps relieve the pressure on the inferior vena cava and improves blood flow. This position allows for optimal circulation and helps alleviate the symptoms associated with supine hypotensive syndrome.
Checking the client's temperature is not necessary in this situation as the symptoms described are not typically associated with a fever. The priority is addressing the client's symptoms related to supine hypotensive syndrome.
Instructing the client to take a brisk walk is not recommended as it may exacerbate their symptoms. Walking increases physical exertion and could further decrease blood flow to the heart.
Providing the client with a glass of orange juice may be helpful if the symptoms were related to low blood sugar (hypoglycemia). However, in this case, the symptoms are more consistent with supine hypotensive syndrome. The priority is to reposition the client to improve blood flow and relieve symptoms. If the client continues to experience symptoms or if there are concerns about low blood sugar, further assessment and appropriate interventions should be implemented.
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