A nurse is preparing to administer a blood transfusion. What action is most important?
a. Correctly identifying client using two identifiers
b. Ensuring informed consent is obtained if required
c. Hanging the blood product with Ringer's lactate
d. Staying with the client for the entire transfusion
ANS: B
If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringer's lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.
You might also like to view...
An adolescent patient is taking combination retroviral therapy for HIV infection. He is not responding as expected. Which action by the nurse is most appropriate?
A. Asking why he does not take the medications B. Assessing the patient for noncompliance C. Consulting a pediatric social worker D. Starting a simpler drug regimen for the HIV
The nurse is providing care to several clients on a medical-surgical unit. Which clients would necessitate a vegetarian diet due to religious beliefs?
Select all that apply. A) A catholic client. B) An Anglican client. C) A Hindu client. D) An Episcopalian client. E) A Seventh-Day Adventist client.
A client with a thought disorder is to be discharged home today, 4 days after having severe
decompensation related to medication noncompliance. The client's medication was restarted, and the client's thought processes are now noted to be more logical and less interrupted by hallucinations. When the client's husband comes to pick her up, he becomes upset and tells the nurse "She shouldn't come home so soon. She's still sick. You must keep her at least a month.". The nurse should a. call the psychiatrist to come to the unit to explain discharge rationale. b. explain that health insurance won't pay for a longer stay for the client. c. explain that the client will continue to improve if she takes medication regularly. d. call security to handle the disturbance and escort the husband off the unit.
A sexually active adolescent asks the school nurse about prevention of sexually transmitted infections (STIs). What should the nurse recommend?
a. Use of condoms b. Prophylactic antibiotics c. Any type of contraception method d. Withdrawal method of contraception