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) "Carry your newborn back to the nursery in your arm when you need to rest.": This statement is not recommended. Carrying the newborn around, especially when the mother is feeling fatigued or unwell, can increase the risk of accidental drops or falls. Newborns should be placed in a bassinet or crib, and if the mother needs to rest, she should use assistance to ensure the baby is safely secured in their sleeping area.
B) "Request that the nurses show their nursing license prior to removing your newborn from the room.": While it’s important to ensure that the staff is authorized to care for the newborn, it may not be practical or necessary to request to see a nursing license every time someone comes to take the baby. Instead, the hospital usually has strict protocols in place for identifying staff, and it is better to rely on the facility's established security measures to verify authorized personnel.
C) "Leave your newborn in the bassinet in your room while you use the bathroom.": This statement is not ideal because, while it may seem safer to leave the baby in the bassinet, the nurse should encourage the mother to keep the baby nearby or alert a nurse to assist if needed. It is safer to have the baby in a secure place or ask for help to avoid the risk of falls or accidents while the mother is not attending to the baby.
D) "Alert the staff if any of your newborn's identification bands are missing.": This is the correct and most important instruction. Newborns should always be closely monitored to prevent abductions or mix-ups, and the identification bands are critical for verifying the baby's identity. If any identification bands are missing, it is essential to notify the staff immediately to ensure the newborn’s safety and prevent any potential security risks.
Correct Answer is B
Explanation
A) Beneficence:
Beneficence refers to the ethical principle of doing good and acting in the best interest of the client. While providing accurate information about the adverse effects of medications contributes to beneficence by ensuring the client’s safety, the specific focus here is on truthfulness in communication, which is more closely aligned with veracity.
B) Veracity:
Veracity is the ethical principle of truthfulness. In this scenario, the nurse is providing honest and accurate information about the medications, including their potential adverse effects. This aligns directly with the principle of veracity, which emphasizes the importance of being truthful and transparent in communication with clients, especially regarding their care and treatment.
C) Justice:
Justice refers to the ethical principle of fairness, ensuring that clients are treated equitably and that their rights are upheld. While the nurse may be demonstrating fairness in the care process, the focus in this scenario is on the truthfulness of the information provided, which is better aligned with the concept of veracity.
D) Autonomy:
Autonomy refers to respecting the client's right to make their own decisions regarding their care. While providing truthful information about medications supports the client’s ability to make informed decisions, the primary ethical principle being demonstrated by the nurse in this scenario is veracity, as the nurse is specifically focused on being truthful with the client.
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