A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take to identify the client? (Select All that Apply.)
Confirm that the room number matches the medical record.
Compare the client identification number to the blood component tag number.
Verify the provider's prescription with another RN.
Ask the client to verbalize if the blood type is Rh-negative or positive.
Scan the barcode on the client's identification band.
Correct Answer : B,E
A. Confirm that the room number matches the medical record. Room numbers should never be used as a sole method to identify a client. Room assignments can change, and relying on them could lead to errors.
B. Compare the client identification number to the blood component tag number. Matching the client identification number to the blood component tag ensures the blood is being administered to the correct client. This is a key step in preventing transfusion errors.
C. Verify the provider's prescription with another RN. While this is an important step in the blood administration process, it is not specifically related to identifying the client.
D. Ask the client to verbalize if the blood type is Rh-negative or positive. Clients may not know their blood type, and relying on their verbal confirmation is unsafe. The blood type must be confirmed through laboratory testing and matched with the blood being administered.
E. Scan the barcode on the client's identification band. Scanning the barcode on the client’s identification band is a reliable and commonly used method for verifying the client’s identity in modern healthcare settings. This ensures that the blood is administered to the correct client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. When the client states he is ready to start the infusion:
While it's important to consider the client's readiness and cooperation, the timing of the infusion should not solely depend on the client's statement. The priority is to start the infusion promptly after receiving the packed red blood cells (PRBCs) from the blood bank to ensure their safety and effectiveness.
B. As soon as the nurse can prepare the client and the administration set:
This choice is the correct answer. After receiving the unit of PRBCs from the blood bank at 1130, the nurse should begin the infusion as soon as possible after preparing the client (ensuring the correct patient, verifying the blood type compatibility, obtaining informed consent, etc.) and the administration set (priming the IV tubing, checking for any leaks, etc.). Prompt administration helps prevent delays that could compromise the quality of the blood product.
C. 2 hours after obtaining blood from the blood bank:
Waiting for 2 hours before starting the infusion is too long and could exceed the recommended timeframe for administering PRBCs after obtaining them from the blood bank. Delaying the infusion for such an extended period could impact the viability and safety of the blood product.
D. When the client has finished eating lunch:
The timing of the client's meal is not a factor in determining when to start the infusion of PRBCs. While it's generally important for the client to have adequate nutrition and hydration, the priority is to administer the blood product promptly after preparation to ensure its efficacy and safety, rather than waiting for unrelated factors such as meal times.
Correct Answer is A
Explanation
A. Work together to see how they can incorporate healthier choices into the foods enjoyed:
This approach emphasizes collaboration between the nurse and the client, focusing on finding ways to incorporate healthier food choices into the client's diet while considering their food preferences and cultural background. By working together, the nurse can help the client identify suitable substitutions, portion control strategies, and meal planning techniques that align with the dietary recommendations for coronary heart disease. This approach promotes active participation, empowers the client to make informed decisions, and increases the likelihood of long-term adherence to the dietary plan.
B. Tell the client if they do not change their diet, they are going to have a myocardial infarction:
This approach uses fear tactics or negative consequences to motivate behavior change, which is generally not recommended in healthcare settings. Fear-based strategies may lead to increased anxiety, stress, or resistance in the client, ultimately hindering motivation and adherence to the dietary plan. Positive reinforcement, education, and collaborative goal-setting are more effective in promoting behavior change and improving adherence to lifestyle modifications.
C. Give the client a list of foods to choose from:
Providing a list of foods can be a helpful tool in guiding food choices and promoting a balanced diet. However, this approach may not address the client's individual preferences, cultural considerations, or practical challenges in implementing dietary changes. Without personalized guidance and support, the client may struggle to navigate food options effectively and may experience difficulties in adhering to the dietary recommendations.
D. It is okay to cheat because of the medications:
Encouraging cheating or deviating from the dietary plan due to medications undermines the importance of dietary modifications in managing coronary heart disease. It is essential to emphasize the significance of following a heart-healthy diet and lifestyle, as medications alone may not be sufficient to manage the condition effectively. Providing education on medication adherence and dietary guidelines, along with ongoing support, helps reinforce the importance of consistent dietary habits in promoting cardiovascular health.
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