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.

Answer and Explanation

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

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Correct Answer is A

Explanation

A. Measuring gastric residual volumes every 4 hours is important to assess the client’s tolerance to the feeding and prevent aspiration.
B. Flushing with saline should only be done as necessary for medication administration and not routinely unless specified by protocol.
C. The rate of feeding should be adjusted based on the client’s tolerance and not increased arbitrarily.
D. The head of the bed should be maintained at 30–45° to reduce the risk of aspiration.

A. Hip arthroplasty 1 week ago B. Acute renal failure 6 months ago C. Chronic obstructive pulmonary disease D. Family history of malignant hypertension

Correct Answer is A

Explanation

A. A recent hip arthroplasty puts the client at risk for bleeding if alteplase is administered, as there is a potential for hemorrhage at the surgical site.
B. Acute renal failure may affect medication clearance but is not a contraindication for alteplase.
C. Chronic obstructive pulmonary disease (COPD) does not place the client at risk for alteplase therapy.
D. A family history of malignant hypertension does not directly affect the safety of alteplase therapy.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase?

Correct Answer is A

Explanation

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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.