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 {"dropdown-group-1":"E","dropdown-group-2":"B"}

Explanation

When interpreting test results, particularly for an infectious disease like tuberculosis (TB), the nurse must prioritize specific infection control measures to prevent the spread of the disease.

The correct actions are:

Wear an N95 respirator mask: This mask is essential for protecting the nurse and others from inhaling airborne pathogens that the client with TB might expel.
Place the client in a room with negative air pressure: This type of room ensures that airborne contaminants do not escape into the hallway or other areas, thereby containing the infection and protecting others in the healthcare facility.

These measures are critical in managing the spread of TB and ensuring the safety of both healthcare workers and other patients.

A. Irrigation of a wound with antibiotic solution B. Insertion of a nasogastric tube C. Placement of a central venous catheter D. Administration of an iron injection using Z-track technique

Correct Answer is C

Explanation

A. Incorrect. Irrigation of a wound with antibiotic solution typically does not require informed consent.
B. Incorrect. Insertion of a nasogastric tube does not usually require informed consent unless it involves specific risks or is part of a research protocol.
C. Correct. Placement of a central venous catheter is an invasive procedure that involves risks, and informed consent is usually required.
D. Incorrect. Administration of an iron injection using the Z-track technique is a routine procedure and does not usually require informed consent.

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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

The nurse reviews the client's test results. Exhibits Complete the following sentence by using the list of options. The nurse should and

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}

Explanation

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client about advanced directives. Which of the following information should the nurse include?

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A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administered 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

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A nurse is contributing to the plan of care for a client who has a major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

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.