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 B
Explanation
A) Social withdrawal: While social withdrawal can be a sign of depression or a worsening cognitive decline in clients with Alzheimer's disease, it does not immediately threaten the client's safety. It is important to monitor and address, but it is not the priority concern that requires immediate intervention.
B) Wandering outside at night: This is the priority issue and requires immediate intervention. Wandering, especially at night, poses a significant safety risk to clients with Alzheimer's disease. The client may become lost, disoriented, or fall, leading to injury. Immediate steps should be taken to ensure the environment is safe, such as installing locks or alarms on doors, and potentially seeking further evaluation or care interventions to manage this behavior.
C) Difficulty articulating words: Difficulty with speech or articulation can occur as part of Alzheimer's disease, especially in the later stages. While it can be distressing for the client and family, it does not present an immediate threat to the client's safety. This issue should be addressed as part of the overall care plan, but it is not as urgent as wandering.
D) Inability to remember their partner's name: Memory loss, including difficulty remembering names, is a common symptom of Alzheimer's disease. While it can be emotionally difficult for both the client and their family, it does not pose an immediate risk to the client’s safety or well-being. This symptom should be monitored, but it is not the top priority for immediate intervention.
Correct Answer is A
Explanation
A) The client's meal tray includes ice cream with fresh fruit: Fresh fruit poses a risk to a neutropenic client because it may harbor harmful bacteria or fungi, which could lead to an infection. Neutropenic clients have a weakened immune system and are more vulnerable to infections, so it is essential to avoid raw or unwashed fruits that can carry harmful pathogens.
B) The client is assigned to a room with negative airflow: A room with negative airflow is a precautionary measure used to prevent the spread of airborne pathogens, particularly for clients with compromised immune systems. This would help reduce the risk of infection by keeping potentially harmful microorganisms from circulating into the room.
C) The client has artificial flowers in the room: While artificial flowers may not pose an immediate risk for infection, they can accumulate dust and other particles that may contribute to a less clean environment. However, they are not as significant a risk factor as the presence of fresh fruits, which can carry live microorganisms capable of causing infections in neutropenic patients.
D) The client's meal tray contains hard boiled eggs: Hard boiled eggs are generally considered safe for neutropenic clients as long as they are properly cooked and stored. Eggs are not a known source of infection in this context, especially when they are cooked and handled properly.
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