Exhibits
The nurse reviews the entries in the medical record.
The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.
Insert a large-bore IV catheter.
Witness the client signing a consent for transfusion.
Flush the transfusion tubing with dextrose 5% in water.
Explain to the client that transfusion reactions are not serious.
Have a second nurse confirm the information on the blood label.
Correct Answer : A,B,E
Correct actions;
A. A large-bore IV catheter is recommended for blood transfusions because it allows for faster and more efficient administration of the blood product. Blood transfusions require proper blood flow to prevent damage to the blood cells, and a larger catheter (usually 18 or 20 gauge) ensures this. A smaller catheter may increase the risk of hemolysis (destruction of red blood cells) or slower transfusion rates, which is not ideal in an emergency situation.
B. It is mandatory to obtain informed consent before any transfusion procedure. The nurse is required to witness the client’s signature on the consent form, ensuring that the client understands the procedure, risks, and benefits. The client’s statement of concern ("I'm really scared...") emphasizes the importance of having a thorough discussion and ensuring they understand what is happening.
E. Two nurses must independently verify the blood product details (such as the blood type and matching the client’s identification) before the transfusion begins. This double-checking procedure is a safety protocol to prevent transfusion errors, such as administering the wrong blood type, which can lead to severe reactions and complications.
Incorrect actions:
C. Dextrose solutions (D5W) should not be used to flush blood transfusion tubing. This is because dextrose solutions can cause hemolysis (destruction of red blood cells) when mixed with blood. The correct solution to flush blood transfusion lines is normal saline (0.9% sodium chloride), as it is compatible with blood products and helps prevent damage to the red blood cells.
D. Transfusion reactions, although rare, can be serious and even life-threatening. It is important for the nurse to provide accurate and clear information about potential transfusion reactions (e.g., allergic reactions, fever, hemolytic reactions, anaphylaxis) and to educate the client on what to expect
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. Sepsis
Sepsis is a systemic infection that can occur during pregnancy, particularly if there is an infection such as chorioamnionitis (infection of the amniotic sac) or endometritis (infection of the uterine lining). The client's fever (38.4°C) could be indicative of infection, which is a risk factor for sepsis.
B. Placenta Previa
Placenta previa occurs when the placenta implants in the lower part of the uterus, covering the cervix. This can cause vaginal bleeding and may lead to complications during labor. However, this is not related to the client's current symptoms.
C. Disseminated Intravascular Coagulation (DIC)
DIC is a serious condition that can occur due to pregnancy complications like abruptio placentae, infection, or severe preeclampsia. However, the client’s symptoms do not indicate bleeding, bruising, or other signs of DIC. The client's blood pressure (130/78) is normal, and there are no indications of placental abruption.
D. Preeclampsia
Preeclampsia is characterized by hypertension and proteinuria. The client’s blood pressure (130/78) is normal, and there are no signs of significant swelling or other symptoms commonly associated with preeclampsia.
E. Preterm Premature Rupture of Membranes (PPROM)
PPROM is the rupture of the membranes (amniotic sac) before 37 weeks gestation, leading to the risk of infection, preterm labor, and other complications. While the client’s membranes are intact at this time, preterm labor at 33 weeks is a risk factor for PPROM.
F. Seizures
Seizures in pregnancy are most commonly seen in conditions like eclampsia, which is a complication of preeclampsia. However, the client does not have the signs of preeclampsia (high blood pressure, proteinuria, edema) that typically lead to eclampsia.
Correct Answer is D
Explanation
A. Negligence involves a failure to provide reasonable care, but it does not apply here since the AP’s
actions were intentional.
B. Battery is the intentional and harmful physical contact with another person without their consent. In the context of healthcare, this could involve actions like physically restraining a patient without consent, administering medication without consent, or any physical contact that is deemed offensive and unwarranted.
C. Malpractice refers to professional negligence by a healthcare provider, which is not the case here.
D. Assault occurs when there is an intentional act that creates a fear of imminent harmful or offensive contact with another person, even if no actual physical contact occurs. In this case, the AP's statement, "If you don't eat, I'll put restraints on your wrists and feed you," is a verbal threat of harm.
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