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 D

Explanation

A. The decision to place a loved one in long-term care is complex and should be made based on the family's needs and situation, not dictated by the nurse.
B. Suggesting the son find other family members for help is a reasonable idea, but it does not directly address his fatigue.
C. While taking care of a loved one is important, making the son feel obligated is not supportive or helpful.
D. Correct. Respite care provides temporary relief to caregivers and can help address the son's fatigue while ensuring his mother's needs are met.

A. "My child continually asks me the same s." B. "I have a difficult time getting my child to eat green vegetables." C. "My child still wets the bed at least two times per week." D. "I have noticed that my child is withdrawn since we switched day care providers."

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: It’s normal for a 4-year-old child to ask the same questions repeatedly. This is a part of their learning process as they are trying to understand the world around them. They often ask the same questions to reassure themselves about the consistency and predictability of the world. However, this is not a priority issue compared to the other options.

Choice B rationale: While it’s important for children to have a balanced diet, including green vegetables, it’s also common for children to be picky eaters. Parents can introduce new foods gradually and make meal times fun to encourage children to eat a variety of foods. However, this is not a priority issue compared to the other options.

Choice C rationale: Bedwetting is common in children and can be a part of their development. Most children outgrow bedwetting by the time they start school. However, if the child is stressed or has a medical condition, it could lead to bedwetting. While this could be a concern, it’s not the priority issue in this scenario.

Choice D rationale: A change in behavior, such as becoming withdrawn, can be a sign of emotional distress in a child. This could be due to a variety of reasons, including changes in their environment like switching day care providers. This is the priority for the nurse to address as it could indicate that the child is having difficulty adjusting to the new day care, which could impact their emotional well-being.

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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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Correct Answer is D

Explanation

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Explanation

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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.