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 C

Explanation

A. Offer the client several choices at mealtimes. Clients with delirium often experience confusion and difficulty processing information. Providing too many choices can increase anxiety and agitation. Instead, offering simple and limited options helps reduce cognitive overload.
B. Alternate daily caregivers. Consistency in caregivers is important for clients with delirium to minimize confusion and distress. Frequent changes in caregivers can contribute to disorientation and make it more difficult for the client to feel secure.
C. Remind the client of the day and time often. Delirium is characterized by fluctuating levels of consciousness and confusion. Frequent orientation to time, place, and situation helps reduce anxiety and supports cognitive function. Using clocks, calendars, and familiar objects in the environment can reinforce orientation.
D. Avoid discussing the client's fears. Clients with delirium may have distressing thoughts or fears that should be acknowledged and addressed. Providing reassurance and a calm, supportive environment can help alleviate anxiety and improve the client's well-being.

A. Oxytocin B. Misoprostol C. Carboprost D. Methylergonovine

Correct Answer is B

Explanation

A. Oxytocin. This medication is typically administered intravenously or intramuscularly to promote uterine contractions and control postpartum hemorrhage. It is not given via the sublingual or rectal route.
B. Misoprostol. This prostaglandin analog is effective in managing postpartum hemorrhage by stimulating uterine contractions. It can be administered via several routes, including oral, sublingual, and rectal, making it a versatile option in hemorrhage control. The rectal route is often preferred in emergencies due to rapid absorption and minimal gastrointestinal side effects.
C. Carboprost. This medication is a prostaglandin used to treat postpartum hemorrhage but is administered intramuscularly rather than sublingually or rectally. It is typically reserved for cases that do not respond to first-line treatments due to its potential for significant gastrointestinal and cardiovascular side effects.
D. Methylergonovine. This ergot alkaloid is effective in reducing postpartum hemorrhage by inducing strong uterine contractions. However, it is administered intramuscularly or orally and is contraindicated in clients with hypertension due to its vasoconstrictive properties.

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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.

Nursing Test Bank

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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.