The nurse is reviewing the client's medical record.

Procedures

Planned endoscopy at 1300.

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.

Witness the client signing a consent for transfusion.

Obtain a large bore IV catheter.

Ensure two nurses confirm the information on the blood label.

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

Explain to the client that transfusion reactions are not serious.

Answer and Explanation

Correct Answer : A,B,C

A.   Correct. The nurse should witness the client signing a consent form for blood transfusion.
Informed consent is necessary for any medical procedure.
B.   Correct. A large bore IV catheter is required for blood transfusion to ensure the smooth flow of blood and prevent clotting.
C.   Correct. Two nurses should confirm the information on the blood label, including the client's identification and the blood type, to prevent errors.
D.   Incorrect. Transfusion tubing is typically flushed with normal saline before attaching it to the patient. Flushing with dextrose 5% in water is not necessary or recommended.
E.   Incorrect. It's important for the nurse to educate the client about potential transfusion reactions, as some reactions can indeed be serious. Providing accurate information helps the client understand the importance of monitoring for any signs of a reaction.

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Correct Answer is ["A","C","D"]

Explanation

A. The nurse should provide the client with written information about advance directives to ensure that the client fully understands their options and can make informed decisions about their healthcare wishes.
B. Not a correct option because it inaccurately states that an advance directive discontinues further care. An advance directive guides the type of care a patient wants or does not want, but it does not automatically discontinue all care.
C. The nurse should communicate the client's advance directives status to other members of the healthcare team through documentation and shift reports. The nurse should also educate the client that an advance directive is a legal document that guides healthcare decisions and must be respected by care providers.
D. The nurse can assist the client in initiating a power of attorney for health care document, which designates a trusted person to make healthcare decisions on behalf of the client if they become unable to make decisions for themselves.

A. The client has state-sponsored health insurance. B. The client's next dressing change is scheduled in 4 hr. C. The client's vital signs are checked every 8 hr. D. The client has developed difficulty ambulating.

Correct Answer is D

Explanation

A. While the client's health insurance status is important for financial considerations, it might not be relevant to the interprofessional team meeting.
B. The timing of the client's dressing change and vital signs are specific care details that may not be essential for the interprofessional team.
D. Correct. The client's difficulty ambulating is a significant change in their condition that may impact care decisions and require input from the interprofessional team.

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The nurse is reviewing the client's medical record. Procedures Planned endoscopy at 1300. 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

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D"]

Explanation

A nurse is participating in an interprofessional team meeting for a client. Which of the following information about the client should the nurse include?

Correct Answer is D

Explanation

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A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

The nurse is reviewing the client's medical record.

Procedures

Planned endoscopy at 1300.

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.