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 B

Explanation

A. Open curtains between clients in semiprivate rooms. Keeping curtains closed between clients helps reduce noise, light, and distractions, promoting a more restful environment. Open curtains can increase disturbances and compromise privacy.
B. Wear shoes with rubber soles. Rubber-soled shoes help minimize noise from footsteps, reducing disruptions to clients' sleep. Hard-soled shoes can create unnecessary noise, contributing to environmental stressors in an acute care setting.
C. Conduct change-of-shift report near the clients' rooms. Shift reports should be conducted away from client rooms to limit noise exposure. Conversations near sleeping clients can be disruptive, reducing sleep quality and contributing to stress.
D. Turn on overhead lights briefly when checking IV lines. Bright overhead lighting can disturb clients' sleep. Using a flashlight or dim bedside lighting is a better approach to minimize disruptions while ensuring safe IV checks.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale for Correct Options:

Compartment syndrome is a serious complication that can occur after a fracture, particularly of a long bone like the femur. It results from increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage.

Edema of the toes suggests swelling, which may indicate increasing pressure within the affected limb. The adolescent is already reporting significant pain (7/10) and has required repeated doses of IV morphine, which may not be sufficient to relieve compartment syndrome pain (a key warning sign). If left untreated, compartment syndrome can cause nerve and muscle damage, ischemia, and even permanent disability.

Rationale for Incorrect Options:

Deep Vein Thrombosis (DVT): DVT is a risk with immobilization, but it usually presents with unilateral swelling, warmth, and pain in the affected limb, not just toe edema.

Fat Embolism Syndrome: This occurs due to fat globules entering circulation after a long bone fracture. Symptoms include respiratory distress, mental status changes, and petechiae, which are not present here.

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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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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.