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. Limiting potassium intake is incorrect because hypokalemia increases the risk of digoxin toxicity.
B. If the child vomits after taking digoxin, the dose should NOT be repeated, as it may be due to toxicity.
C. Digoxin should NOT be mixed with large amounts of liquid, as the child may not finish it, leading to an incomplete dose.
D. Drinking water helps remove residual digoxin from the mouth, preventing irritation and ensuring the full dose is swallowed.
Correct Answer is D
Explanation
A. A heart rate of 90/min is within normal limits.
B. Discomfort at the insertion site is expected and should be managed appropriately.
C. Bounding pulses in the affected extremity can occur due to arterial flow after catheterization but are not necessarily abnormal unless accompanied by other concerning findings.
D. A hematoma at the catheter insertion site may indicate bleeding or vascular injury and should be reported promptly.
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