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 C

Explanation

A. "Why are you changing your mind about the procedure?" This question may come across as confrontational or judgmental. It does not directly address the client’s need for information or support.
B. "This procedure is perfectly safe." This response is dismissive and provides false reassurance. The nurse should avoid minimizing the client's concerns.
C. "I will contact the provider to let her know." When a client expresses uncertainty about undergoing a procedure, the nurse's priority is to notify the provider. The provider is responsible for addressing the client’s concerns, clarifying the procedure, and ensuring informed consent. The client's autonomy must be respected, and they have the right to withdraw consent at any time.
D. "You should discuss your concerns with your family!" While family support can be helpful, the decision to proceed or not is ultimately between the client and the provider. Directing the client to the family may undermine their autonomy.

A. "I will use a Class A extinguisher for an electrical fire." B. "I should spray the extinguisher from side to side on the fire." C. "I will attempt to extinguish the fire before calling the fire department." D. "I should change the batteries in my smoke alarms every 2 years."

Correct Answer is B

Explanation

A. "I will use a Class A extinguisher for an electrical fire." Class A extinguishers are for fires involving wood, paper, and cloth, not electrical fires. Class C is appropriate for electrical fires.
B. "I should spray the extinguisher from side to side on the fire." This technique is recommended to ensure the fire is completely extinguished.
C. "I will attempt to extinguish the fire before calling the fire department." The fire department should be called immediately to ensure prompt response, even if the fire appears controllable.
D. "I should change the batteries in my smoke alarms every 2 years." Batteries in smoke alarms should be changed at least once a year or as recommended by the manufacturer.

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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

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