The nurse reviews the entries in the medical record.

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is []

Explanation

Potential Condition: Deep Venous Thrombosis (DVT)

Actions to Take:

Request a prescription for a lower extremity Doppler flow study

Check for pedal pulses and signs of ischemia

Parameters to Monitor:

PT/INR and platelet count

Signs of bleeding after anticoagulation initiation

Rationale:

DVT: The client presents with classic signs of DVT, including: unilateral leg swelling, pain and warmth in the affected limb, recent immobility (limited ambulation after surgery). DVT is a serious complication that can lead to pulmonary embolism (PE) if the clot dislodges.

Actions to Take:

Request a prescription for a lower extremity Doppler flow study: A Doppler ultrasound is the gold standard for diagnosing DVT by assessing blood flow and detecting clots.

Check for pedal pulses and signs of ischemia: Ensuring adequate circulation is crucial to monitor for complications like arterial occlusion.

Parameters to Monitor:

PT/INR and platelet count: If anticoagulation therapy is initiated, monitoring PT/INR (for warfarin) or platelet count (for heparin-induced thrombocytopenia) is essential.

Signs of bleeding after anticoagulation initiation: Anticoagulants increase the risk of bleeding, so assessing for bruising, hematuria, or GI bleeding is critical.

A. A client who was just given a glass of orange juice for a low blood glucose level B. A client who has 100 mL of fluid remaining in his IV bag C. A client who is scheduled for a procedure in 1 hr D. A client who received a pain medication 30 min ago for postoperative pain

Correct Answer is A

Explanation

A. Correct – This client is at risk for hypoglycemia, which can cause altered mental status, seizures, and coma. The nurse should reassess blood glucose levels to ensure the intervention was effective.
B. Incorrect – The client with an IV infusion running low does need attention but is not at immediate risk. The nurse can replace the IV fluid after checking on the more critical client.
C. Incorrect – The client scheduled for a procedure needs preparation, but there is no immediate threat to safety.
D. Incorrect – The client who received pain medication 30 minutes ago needs reassessment, but pain management is a lower priority than monitoring a potentially unstable client.

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The nurse reviews the entries in the medical record. Exhibits The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

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Correct Answer is A

Explanation

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The nurse reviews the entries in the medical record.

Exhibits

The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.