A nurse receives 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?

Inform the charge nurse of the need to reassign the client's care.

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.

Answer and Explanation

The Correct Answer is B

A. Informing the charge nurse of the need to reassign the client’s care is unnecessary unless the nurse is unable to provide safe and competent care for the transfusion.
B. Obtaining informed consent is essential before a blood transfusion to ensure the client is aware of the procedure's purpose, benefits, and potential risks.
C. Delegating the client's care to another RN may be appropriate if the nurse lacks competence with transfusions, but obtaining consent is a priority.
D. Accessing the nursing information system for transfusion guidelines is helpful, but obtaining consent takes precedence before proceeding with the transfusion.

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Correct Answer is A

Explanation

A. Reporting the concern to the charge nurse is the appropriate action, as it ensures that the issue is addressed through proper channels. The charge nurse can investigate and determine if further action is needed, such as reviewing the medication administration process.
B. Questioning the nurse directly could lead to confrontations and is not the correct procedure for handling potential discrepancies in medication administration.
C. Notifying the pharmacy is unnecessary at this point because the issue concerns administration rather than medication supply or errors with the prescription.
D. While documenting the client’s report is important, simply documenting the client’s claim without notifying the charge nurse does not fully address the concern.

A. Review evidence-based literature to determine best practices in the shift reporting process. B. Organize a task force to review interventions to change the shift reporting process. C. Create a new shift reporting process to present at the next staff meeting. D. Develop a strategy to alert other nurses about the need for changes in the shift reporting process.

Correct Answer is A

Explanation

A. Reviewing evidence-based literature is essential to understand best practices in shift reporting and can inform the development of effective interventions. This foundational step helps ensure that any proposed changes are supported by research and proven methods.
B. While organizing a task force can be beneficial, it should occur after understanding the current best practices, as the task force's efforts would be better guided with existing evidence.
C. Creating a new reporting process without first gathering information or reviewing best practices may result in ineffective or unnecessary changes.
D. Developing a strategy to alert nurses is important, but it should be based on informed decisions derived from literature and data analysis, which should come first.

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A nurse receives 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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