The nurse reviews the entries in the medical record.
The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.
Have a second nurse confirm the Information on the blood label.
Witness the client signing a consent for transfusion.
Explain to the client that transfusion reactions are not serious.
Flush the transfusion tubing with dextrose 5% in water.
Insert a large-bore IV catheter.
Correct Answer : A,B,E
A. Have a second nurse confirm the information on the blood label: Two nurses must verify the blood product (blood type, Rh factor, client identification) before administration to prevent transfusion reactions due to mismatched blood.
B. Witness the client signing a consent for transfusion: Blood transfusion requires informed consent because of risks such as hemolytic reactions, febrile reactions, and infections. The nurse can witness the signature, but the provider must explain the risks, benefits, and alternatives.
C. Explain to the client that transfusion reactions are not serious: This is false and misleading. Blood transfusion reactions can range from mild (fever, chills) to life-threatening (anaphylaxis, hemolysis, sepsis). The nurse should instead educate the client on signs of a transfusion reaction (fever, chills, back pain, difficulty breathing, hypotension) and instruct them to report any symptoms immediately.
D. Flush the transfusion tubing with dextrose 5% in water: Dextrose (D5W) should never be used to flush blood transfusion tubing because it can cause hemolysis of red blood cells. Instead, 0.9% sodium chloride (normal saline) is the only compatible fluid for flushing blood transfusion tubing.
E. Insert a large-bore IV catheter: A large-bore (18- to 20-gauge) IV catheter is required for blood transfusion to ensure adequate flow and prevent clotting. Smaller catheters (22- to 24-gauge) are inadequate for rapid blood transfusions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. The test is not repeated at 2 months unless results are inconclusive.
B. Blood for the test is collected from the newborn’s heel, not the inner elbow.
C. Newborn genetic screening should be performed after 24 hours of age, once the baby has had adequate feedings, which ensures accurate metabolic screening.
D. The baby does not need to drink water before the test.
Correct Answer is B
Explanation
A. Incorrect – The provider, not the nurse, determines if the surgery is medically necessary.
B. Correct – A health care surrogate (or durable power of attorney for health care) makes medical decisions on behalf of an incapacitated client. The nurse should ensure the surrogate understands the risks and benefits.
C. Incorrect – Sending an unsigned informed consent form to the risk manager does not address the need for legal consent from the surrogate.
D. Incorrect – The family's opinions are considered, but only the legally designated surrogate has the authority to make the decision.
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