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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","C","D","G"]

Explanation

A. Respiratory complaint: A 4-day productive cough with fatigue and night sweats raises concern for a respiratory infection, including tuberculosis (TB) or pneumonia. Further evaluation, including chest imaging and sputum studies, is warranted.
B. Temperature: A low-grade fever (38.1°C/100.5°F) for several days, along with night sweats, suggests a possible infectious process, requiring further investigation.
C. Sputum characteristics: Blood-tinged sputum raises concern for TB, bronchitis, pneumonia, or malignancy, necessitating a sputum culture and acid-fast bacillus (AFB) testing.
D. Weight: Unintentional weight loss (5 lb in 1 week) and decreased appetite can indicate chronic infection, malignancy, or another systemic illness, necessitating further evaluation.
G. Travel history: Recent travel to South Africa, a country with a high TB prevalence, increases the risk of tuberculosis exposure and justifies further screening.
Incorrect Choices:
E. Blood pressure: 112/88 mm Hg is within the normal range and does not require further evaluation.
F. Oxygen saturation: 98% on room air is normal and does not indicate respiratory compromise.
H. Heart rate: 98/min is slightly elevated but could be due to fever or mild dehydration. It is not a primary concern.

A. Document the infiltration. B. Elevate the arm. C. Apply a warm compress. D. Stop the infusion.

Correct Answer is D

Explanation

A) "Document the infiltration.": While documenting the infiltration is important for medical records, it is not the most immediate action to take. The nurse’s first priority should be to stop the infusion to prevent further complications such as tissue damage or excessive fluid accumulation around the insertion site.

B) "Elevate the arm.": Elevating the arm may help with swelling if the infiltration is mild, but it does not address the primary issue of preventing further fluid leakage. Stopping the infusion is the priority action to stop the infiltration from worsening.

C) "Apply a warm compress.": A warm compress can help with the absorption of infiltrated fluid, but it should not be applied until the infusion is stopped. If the infusion continues while a compress is applied, it could lead to further tissue damage and more discomfort for the client.

D) "Stop the infusion.": The first action should be to stop the IV infusion to prevent further infiltration. This stops the flow of fluid into the tissue, which is crucial in minimizing the risk of tissue damage and complications. After stopping the infusion, the nurse can assess the site, document the findings, and take additional actions, such as applying a warm compress or elevating the arm.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who presents to the emergency department A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation? Select all that apply.

Correct Answer is ["A","B","C","D","G"]

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for the client?

A nurse is collecting a health history from the guardian of a 4year old child. Which of the following statements by the guardian is the priority for the nurse to address?

A nurse is collecting data for a client who is receiving enteral tube feeding. They should identify that which of the following findings is a manifestation of fluid overload?

A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is reinforcing teaching with a caregiver of a 2-month-old infant about developmentally appropriate toys. which of the following toys should the nurse include in the teaching?

A nurse at a long-term care facility is reviewing the plan of care for client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is verifying informed consent for a client who is preoperative for vaginal hysterectomy. Which of the following statements should thenurse identify as an indication that the client has given informed consent?

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?

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.