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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While reviewing previous appraisals may provide some context, it is not the most effective way to evaluate current performance.
B. Gathering information from clients provides direct feedback about the AP’s performance and interactions, making it a valuable input for performance appraisals.
C. Examining the job description is helpful for understanding expectations, but it does not provide specific performance insights needed for an appraisal.
D. Peer reviews can be informative, but they may not reflect the full scope of the AP's duties and interactions with clients, which are critical for a comprehensive performance appraisal.
Correct Answer is A
Explanation
A. Waiting 2 minutes between suction passes allows the client to recover and helps to prevent hypoxia, demonstrating an understanding of the suctioning procedure.
B. Wearing clean gloves during suctioning is not appropriate; sterile gloves should be used to prevent introducing pathogens into the airway.
C. The recommended suction pressure for adults is typically between 80 and 120 mm Hg; therefore, setting the suction to 200 mm Hg is too high and could cause trauma to the airway.
D. Suction should be applied only while withdrawing the catheter, not while inserting it, to minimize trauma and prevent oxygen deprivation.
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