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.

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Client	Tag colour	Rationale
Client 1	Red	The significant blood loss and tourniquet application indicate immediate life-threatening injuries that are survivable with prompt intervention. The heart rate of 54/min is concerning for hypovolemic shock.
Client 2	Black	Fixed and dilated pupils, no pulse, and no spontaneous respirations indicate the client is deceased or has non-survivable injuries.
Client 3	Red	Disorientation, multiple lacerations with significant bleeding, and elevated heart and respiratory rates indicate hemodynamic instability requiring immediate intervention.
Client 4	Yellow	The client is stable, with a suspected arm fracture and minor abrasions. Treatment can be delayed without significant risk of deterioration.

A. Applying the restraint over the client's gown B. Using a quick-release knot to secure the restraint C. Placing the restraint across the client's chest D. Tying the restraint to the bed frame

Correct Answer is C

Explanation

A. Applying the restraint over the client's gown: Restraints should be applied over clothing or a gown to prevent skin irritation and ensure comfort.
B. Using a quick-release knot to secure the restraint: A quick-release knot is the recommended method for securing restraints to ensure they can be removed quickly in an emergency.
C. Placing the restraint across the client's chest: Belt restraints should be placed around the waist, not the chest, as chest placement can impair breathing.
D. Tying the restraint to the bed frame: Restraints should be tied to the bed frame (not the side rails) to prevent injury during bed movement.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is assisting in the care of clients during a mass casualty event. Exhibits For each client, click to specify if the client should be assigned a red. yellow, or black tag. A tag color may be assigned to more than one client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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Correct Answer is C

Explanation

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