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 B
Explanation
A. Incorrect. Mentioning the completion of an incident report is appropriate but not sufficient in explaining the incident.
B. Correct. Documenting the client's own statement about the fall is essential for accuracy and clarity in the medical record.
C. Incorrect. While footwear might contribute to falls, it's important to include the client's own account of the fall in the documentation.
D. Incorrect. While noting the absence of visible injuries is relevant, it's more important to document the circumstances leading to the fall.
Correct Answer is D
Explanation
The correct answer is choiced. Route.
Choice A rationale:
The time of administration is typically specified in the prescription and does not usually require clarification unless there are specific concerns about timing with other medications or meals.
Choice B rationale:
The medication, erythromycin, is clearly specified in the prescription. There is no ambiguity about which medication is being prescribed.
Choice C rationale:
The dosage of 500 mg is clearly stated and is a standard dose for erythromycin. There is no need to clarify this unless there are specific patient concerns or conditions that might affect dosing.
Choice D rationale:
The route of administration (e.g., oral, intravenous) is crucial information that must be clarified if not specified.Erythromycin can be administered in multiple ways, and the effectiveness and side effects can vary depending on the route
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