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
A. While male gender is associated with a higher likelihood of violence, it is not the best predictor.
B. A history of being in prison suggests past criminal behavior but does not necessarily indicate violence.
C. A history of violent behavior is the strongest predictor of future violence.
D. Delusions may contribute to violent behavior, but not all individuals with delusions act violently.
Correct Answer is B
Explanation
A. By age 2, the chest circumference typically equals or slightly exceeds the head circumference (head circumference is larger at birth but becomes proportionate as the child grows).
B. A protruding abdomen is normal in toddlers due to immature abdominal muscles.
C. Deciduous teeth (baby teeth) are not naturally lost until around age 6 when permanent teeth begin to erupt.
D. Fontanels should be closed by 18 months, so they should not be palpable in a 2-year-old.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.