The nurse reviews the entries in the medical record.

Exhibits

The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Stay with the client for the first 15 min of the transfusion.

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

Document the blood product transfusion in the client's medical record.

Obtain the first unit of packed RBCs from the blood bank.

Start an IV bolus of lactated Ringer's solution.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.

Explanation:.

Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

The nurse should sit in a chair next to the bed to place the client at ease. This position allows the nurse to maintain eye contact, show interest, and respect the client’s personal space. Sitting on the bed next to the client (choice A) is wrong because it invades the client’s privacy and comfort zone. Standing at the side of the bed (choice C) or at the foot of the bed (choice D) is wrong because it creates a power imbalance and may intimidate the client.

The nurse should also consider the client’s condition and preferences when choosing a position for the interview. For example, a client who is on bedrest may have difficulty hearing or seeing the nurse if they are too far away or at an awkward angle.

Therefore, the nurse should adjust their position accordingly and ask the client if they are comfortable with it.

A. Monitor progress of task completion with each AP. B. Review the skill level and qualifications of each AP. C. Evaluate the APs' performance of each task. D. Communicate appropriate tasks to the APS with specific expectations

Correct Answer is B,D,A,C

Explanation

B. Review the skill level and qualifications of each AP.

Before delegating tasks, the nurse should assess the skill level and qualifications of each AP to ensure they have the necessary knowledge and training to perform the assigned tasks safely and effectively.

D. Communicate appropriate tasks to the APs with specific expectations.

The nurse should clearly communicate the tasks to be delegated to each AP. This includes providing specific instructions, expectations, and any necessary information to ensure the APs understand what is expected of them and can perform the tasks correctly.

A. Monitor progress of task completion with each AP.

Once the tasks are assigned, the nurse should periodically check in with each AP to monitor the progress of task completion. This allows the nurse to provide support, answer questions, and ensure that tasks are being performed as expected.

C. Evaluate the APs' performance of each task.

After the tasks are completed, the nurse should evaluate the APs' performance of each task. This evaluation helps identify any areas for improvement, additional training needs, and overall competency of the APs.

Delegating tasks to assistive personnel is an essential aspect of nursing practice. Following this sequence of steps helps ensure that tasks are delegated appropriately and that the care provided is safe, efficient, and aligned with the APs' capabilities. Regular communication and feedback are essential to effective task delegation and teamwork within the healthcare setting.

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The nurse reviews the entries in the medical record. Exhibits The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?

Correct Answer is B

Explanation

A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs.

Correct Answer is B,D,A,C

Explanation

A nurse is caring for a client who has experienced a stroke and is moving in with an adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?

A nurse is caring for a client Exhibits A nurse is reviewing the client's electronic medical record. Which of the following findings requires follow-up? Select all that apply.

A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client?

The nurse continues to care for the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session?

A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

The nurse reviews the entries in the medical record.

Exhibits

The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.