The nurse is reviewing the client's medical record.

Exhibits

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

Obtain a large-bore IV catheter.

Explain to the client that transfusion reactions are not serious.

Ensure two nurses confirm the information on the blood label.

Ensure the transfusion tubing is flushed with dextrose 5% in water.

Witness the client signing consent for transfusion.

Answer and Explanation

Correct Answer : A,C,E

A. Obtain a large-bore IV catheter. A large-bore IV catheter (18-gauge or larger) is necessary for blood transfusion to allow for rapid administration and reduce the risk of hemolysis. The provider has already prescribed this intervention.
B. Explain to the client that transfusion reactions are not serious. This statement is inaccurate and misleading. While many transfusion reactions are mild, some can be life-threatening, such as hemolytic reactions or anaphylaxis. The nurse should educate the client about signs and symptoms of a transfusion reaction and instruct them to report any discomfort or unusual sensations immediately.
C. Ensure two nurses confirm the information on the blood label. Before administering blood, two nurses must verify the blood product against the client's identification band, medical record, and blood bank documentation to prevent transfusion errors.
D. Ensure the transfusion tubing is flushed with dextrose 5% in water. Blood products should only be administered with normal saline (0.9% sodium chloride) because dextrose-containing solutions can cause red blood cell hemolysis. The nurse should ensure the IV tubing is primed with normal saline before starting the transfusion.
E. Witness the client signing consent for transfusion. Informed consent is required before administering a blood transfusion. While obtaining consent is the provider’s responsibility, the nurse can witness the signing and ensure that the client understands the procedure.

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Correct Answer is D

Explanation

A. "I should enable the airbag when my baby is in the front seat of the car." Airbags deploy with significant force and can cause severe injury or fatal trauma to an infant in a car seat, especially if placed in the front seat. The safest position for an infant is in the back seat, rear-facing, as this provides the best protection in the event of a crash. If the front seat must be used, the airbag should be deactivated to prevent impact injuries.
B. "I should position the car seat's retainer clip at the level of my baby's belly button." The car seat’s retainer clip should be positioned at armpit level to properly secure the harness and keep the baby restrained during a collision. If the clip is placed too low, such as at the belly button, the harness straps may not fit snugly around the shoulders, increasing the risk of the baby slipping out of the seat upon impact.
C. "I should place my baby in the car seat at a 90-degree angle." A 90-degree angle is too upright for a newborn and can lead to airway obstruction due to the infant's weak neck muscles and large head size. The car seat should be reclined at approximately 45 degrees to maintain an open airway and prevent the baby’s head from falling forward, which could restrict breathing and cause positional asphyxia.
D. "I should keep my baby rear-facing in the car seat until she is 2 years old." Rear-facing car seats provide optimal protection by supporting the baby’s head, neck, and spine in the event of a crash, reducing the risk of serious injury. The American Academy of Pediatrics recommends keeping infants in a rear-facing position until at least the age of 2 or until they exceed the car seat's height and weight limits. This positioning distributes crash forces more evenly across the child's body, minimizing the risk of spinal cord and head injuries.

A. A B. B C. C D. D

Correct Answer is B

Explanation

A. Pivotal Joint (Radius-Ulnar Joint) –A pivot joint allows for rotation around a single axis. The joint between the radius and ulna at the elbow allows the forearm to rotate (pronation/supination). This is not a ball-and-socket joint because it does not allow movement in multiple planes.
B. A ball-and-socket joint allows for the greatest range of motion in multiple directions, including flexion, extension, abduction, adduction, and rotation. Examples are the hip joint (femur-acetabulum) and shoulder joint (humerus-glenoid cavity).
C. A hinge joint allows movement in only one plane (like a door hinge) with flexion and extension. Examples are the knee joint (tibia-femur) and elbow joint (humerus-ulna) function as hinge joints. It is not a ball-and-socket joint because it does not allow rotation or movement in multiple planes.
D. A condyloid (ellipsoidal) joint allows movement in two planes (flexion/extension and abduction/adduction), but no rotation. Examples are the wrist joint (radiocarpal joint) allows side-to-side and up-and-down movements but lacks full rotation.

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The nurse is reviewing the client's medical record. Exhibits The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

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The nurse is reviewing the client's medical record.

Exhibits

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.