The nurse reviews the entries in the medical record.
The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.
Have a second nurse confirm the Information on the blood label.
Witness the client signing a consent for transfusion.
Explain to the client that transfusion reactions are not serious.
Flush the transfusion tubing with dextrose 5% in water.
Insert a large-bore IV catheter.
Correct Answer : A,B,E
A. Have a second nurse confirm the information on the blood label: Two nurses must verify the blood product (blood type, Rh factor, client identification) before administration to prevent transfusion reactions due to mismatched blood.
B. Witness the client signing a consent for transfusion: Blood transfusion requires informed consent because of risks such as hemolytic reactions, febrile reactions, and infections. The nurse can witness the signature, but the provider must explain the risks, benefits, and alternatives.
C. Explain to the client that transfusion reactions are not serious: This is false and misleading. Blood transfusion reactions can range from mild (fever, chills) to life-threatening (anaphylaxis, hemolysis, sepsis). The nurse should instead educate the client on signs of a transfusion reaction (fever, chills, back pain, difficulty breathing, hypotension) and instruct them to report any symptoms immediately.
D. Flush the transfusion tubing with dextrose 5% in water: Dextrose (D5W) should never be used to flush blood transfusion tubing because it can cause hemolysis of red blood cells. Instead, 0.9% sodium chloride (normal saline) is the only compatible fluid for flushing blood transfusion tubing.
E. Insert a large-bore IV catheter: A large-bore (18- to 20-gauge) IV catheter is required for blood transfusion to ensure adequate flow and prevent clotting. Smaller catheters (22- to 24-gauge) are inadequate for rapid blood transfusions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The client is at highest risk for developing mastitis evidenced by the client's cracked nipple.
Rationale:
Mastitis is a breast infection that can occur in breastfeeding individuals, often caused by bacteria entering through cracked or damaged nipples.
The client reports nipple discomfort throughout feeding and has a visible crack on the left nipple, which increases the risk of infection.
Mastitis symptoms include breast pain, swelling, redness, fever, and flu-like symptoms. If untreated, it can lead to an abscess.
Incorrect Options:
Endometritis is an infection of the uterine lining, but the client has no uterine tenderness, fever, or foul-smelling lochia, making this unlikely.
Perineal hematoma is a collection of blood in the perineal area, often presenting with severe pain and pressure. The client only reports mild perineal discomfort (2/10), which is not suggestive of a hematoma.
Correct Answer is C
Explanation
A. A residual of 65 mL 1 hr postprandial is within acceptable limits and does not indicate an increased risk for aspiration.
B. Being in a high-Fowler's position (sitting upright) during feedings actually reduces the risk of aspiration.
C. A history of gastroesophageal reflux disease (GERD) predisposes the client to aspiration, as reflux increases the risk that gastric contents may enter the airway.
D. Although a high-osmolarity formula can cause gastrointestinal distress, it is not as directly related to aspiration risk as GERD.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.