The nurse is reviewing the client's medical record.
The nurse is assisting with the care the client prior to a blood transfusion
Which of the following actions should the nurse take? Select all that apply.
Explain to the client that transfusion reactions are not serious.
Ensure two nurses confirm the information on the blood label.
Obtain a large- bore IV catheter.
Witness the client signing a consent for transfusion.
Ensure the transfusion tubing is flushed with dextrose 5% in water
Correct Answer : B,C,D
B. Ensure two nurses confirm the information on the blood label: Before initiating a blood transfusion, two nurses must verify the client’s identity, blood type, and compatibility with the donor blood. This step is essential to prevent transfusion reactions due to mismatched blood.
C. Obtain a large-bore IV catheter: A large-bore IV catheter (18–20 gauge) is necessary to facilitate the transfusion of packed red blood cells (PRBCs). A smaller gauge may cause hemolysis or delay administration.
D. Witness the client signing a consent for transfusion: A blood transfusion is an invasive procedure requiring informed consent. The nurse ensures the client understands the risks, benefits, and potential complications before signing the consent form.
Incorrect Options:
A. Explain to the client that transfusion reactions are not serious: This is incorrect because transfusion reactions can range from mild allergic responses to life-threatening anaphylaxis or hemolytic reactions. The nurse should educate the client on symptoms to report, such as fever, chills, or dyspnea.
E. Ensure the transfusion tubing is flushed with dextrose 5% in water: Blood products should only be administered with 0.9% sodium chloride to prevent hemolysis. Using dextrose solutions can cause red blood cell aggregation and clot formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "Our child has a better grasp of reality":
While methylphenidate can improve focus and reduce impulsivity in children with ADHD, a "better grasp of reality" is not a typical or direct effect of the medication. The goal of medication like methylphenidate is to manage symptoms of ADHD, such as inattention, hyperactivity, and impulsivity, rather than altering the child's sense of reality. Therefore, this statement does not reflect an expected outcome of the medication.
B) "Our child has lost some weight since his last appointment":
Weight loss can be a side effect of methylphenidate, as it may reduce appetite. However, this is not an indication that the medication is effective in managing ADHD symptoms. A decrease in weight does not correlate with the desired effects of improved concentration or behavior control. In fact, parents should be educated on monitoring the child’s nutritional intake and discussing any concerns about weight loss with the healthcare provider.
C) "Our child has increased his daily caloric intake":
While it is beneficial for children taking methylphenidate to maintain adequate nutrition, an increase in caloric intake is not directly related to the medication’s effectiveness in treating ADHD. The goal is to improve symptoms of inattention, hyperactivity, and impulsivity, not to focus on changes in food consumption.
D) "Our child is able to complete his homework on time":
This statement is a clear indicator that methylphenidate is working effectively. One of the main goals of treating ADHD is to improve the child's ability to focus and complete tasks, such as homework, within a reasonable time frame. The child being able to complete homework on time reflects the positive effect of the medication in improving concentration, attention, and task completion.
Correct Answer is A
Explanation
A) Time: The time of administration is an important factor to clarify. The prescription specifies erythromycin 500mg four times per day, but it does not specify the exact times the medication should be administered. The nurse should clarify the specific times to ensure the medication is given at proper intervals, especially considering the potential for drug interactions and the timing of meals, which may impact absorption.
B) Dosage: The dosage of 500mg is specified clearly in the prescription. There is no indication that the dosage is incorrect or needs clarification. Erythromycin 500mg four times per day is a standard dose for certain infections, so no issues are apparent with the dosage itself.
C) Route: The route of administration (oral, intravenous, etc.) is not specified in the question but is typically understood unless otherwise stated. However, in the context of erythromycin, the most common route is oral. Unless there’s uncertainty about the route, it does not need clarification.
D) Medication: The medication is clearly identified as erythromycin, which is a known antibiotic. There is no ambiguity in the medication prescribed, so there is no need for clarification in this regard. The focus should be on confirming the time of administration.
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