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 D
Explanation
A. A bronchodilator should be given before postural drainage to help open the airways.
B. The procedure should be done 2 to 4 times daily, not just twice a day.
C. A cupped hand, not a flat hand, should be used for percussions to loosen mucus.
D. Postural drainage should be done before meals to reduce the risk of vomiting or aspiration.
Correct Answer is D
Explanation
A. Incorrect – Lying in a quiet room can increase hallucinations because of the lack of external stimuli.
B. Incorrect – Referring to hallucinations as real reinforces delusional thinking. Instead, the nurse should acknowledge the client’s experience while reorienting them to reality.
C. Incorrect – Avoiding eye contact can appear dismissive and hinder therapeutic communication.
D. Correct – Assessing the hallucinations directly helps determine their content, frequency, and potential for harm (e.g., suicidal or homicidal commands).
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