A nurse receives a change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?
Obtain informed consent from the client for the blood transfusion.
Delegate the client's care to an RN.
Access the nursing information system for guidelines about blood transfusions.
Inform the charge nurse of the need to reassign the client's care.
The Correct Answer is C
A. Obtain informed consent from the client for the blood transfusion: Verifying that informed consent is obtained is essential, but obtaining consent is the provider's responsibility. The nurse's role is to ensure the consent has been signed and documented.
B. Delegate the client's care to an RN: If the nurse receiving the shift report is already an RN, delegating the care to another RN is unnecessary unless there are specific time constraints or workload considerations.
C. Access the nursing information system for guidelines about blood transfusions: This is an appropriate action to ensure that institutional policies and guidelines are followed regarding blood administration, which may include steps for patient identification, infusion rates, and monitoring for reactions.
D. Inform the charge nurse of the need to reassign the client's care: This is typically not necessary unless the assigned nurse lacks the competency to administer blood products or has competing responsibilities that prevent safe monitoring of the transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Carry bedridden clients to safety by lifting them onto your back: This is not a safe or recommended practice for evacuating bedridden clients.
B. Ask ambulatory clients to help to move clients in wheelchairs: Ambulatory clients should be prioritized for independent evacuation rather than being assigned caregiving tasks.
C. Place dry towels around the bases of doors: This can help to prevent smoke from entering the room and provide some protection while awaiting rescue.
D. Aim the extinguisher at the top of the fire: The correct action is to aim the extinguisher at the base of the fire, where the fuel source is.
Correct Answer is B
Explanation
A. Asking the client about the presence of pain. This is part of the assessment phase, as it involves gathering data.
B. Reinforcing teaching about the client's diagnosis. Teaching is part of the implementation phase, where planned interventions are carried out.
C. Establishing the priorities of client care. This is part of the planning phase, where care priorities are determined.
D. Comparing the client's current laboratory values to previous results. This is part of the evaluation phase, where the nurse assesses progress toward goals.
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