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) Cimetidine: Cimetidine is an H2 receptor antagonist used to treat gastrointestinal issues like heartburn or ulcers. It does not have a known significant interaction with enoxaparin. Therefore, it is generally considered safe to use with enoxaparin, but it may require monitoring for other potential drug interactions, such as those with warfarin, not enoxaparin specifically.
B) Docusate: Docusate is a stool softener commonly used to prevent constipation. It does not interact with enoxaparin and is safe for use with the medication. It helps relieve constipation without increasing bleeding risks, which is a concern with certain other medications.
C) Calcium supplement: Calcium supplements are generally safe to use with enoxaparin. There is no significant interaction between calcium and enoxaparin, and calcium is often recommended for clients to maintain bone health, especially in those who are at risk of osteoporosis. Therefore, calcium supplements do not pose a risk when taken with enoxaparin.
D) Naproxen: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that increases the risk of bleeding. NSAIDs, including naproxen, inhibit platelet aggregation, which can potentiate the anticoagulant effects of enoxaparin and increase the risk of bleeding. Therefore, naproxen should be avoided in clients taking enoxaparin.
Correct Answer is D
Explanation
A) "I will wash my baby’s head using a moist towelette": Using a moist towelette to wash a newborn’s head is not the best approach. Newborns should be bathed gently with warm water and mild soap, especially for sensitive areas like the scalp. A moist towelette could irritate the baby’s delicate skin or lead to unnecessary chemicals on the skin.
B) "I will give my baby a bath every day": Giving a newborn a bath every day is not typically necessary. Bathing a newborn 2-3 times per week is usually sufficient to keep the baby clean without drying out the skin. Daily baths can be too harsh on a newborn’s skin, especially in the first few weeks.
C) "I will bathe my baby under a faucet of running water": Bathing a newborn under running water can be dangerous, as it may be difficult to control the temperature of the water or the baby could be at risk of slipping. It is safer to use a basin of warm water and a soft washcloth to gently bathe the baby.
D) "I will wash my baby's face with a warm, wet washcloth without soap": This is the correct and safe approach to washing a newborn’s face. Newborns have very sensitive skin, and it’s best to wash the face with just warm water and a soft washcloth to avoid irritation. Using soap on the face may dry out or irritate their delicate skin.
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