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. Shortness of breath is more common in fluid volume overload (hypervolemia) rather than hypovolemia.
B. Epistaxis (nosebleeds) is not a common symptom of hypovolemia; it is more associated with hypertension or clotting disorders.
C. Hypovolemia (fluid volume deficit) leads to dizziness due to decreased cerebral perfusion and orthostatic hypotension.
D. Headaches can occur in fluid overload or hypertension, but dizziness is the more classic symptom of hypovolemia.
Correct Answer is C
Explanation
A. Asking about medication adherence is important but not the priority when assessing for immediate harm.
B. Asking how long the hallucinations have occurred is useful for history-taking but does not assess immediate risk.
C. The priority is safety. Asking what the voices are saying helps determine if the hallucinations are command hallucinations, which may instruct the client to harm themselves or others.
D. This response acknowledges the client's experience but does not assess for danger.
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