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A nurse is preparing to administer a blood transfusion. What action is most important?
- A. Correctly identifying client using two identifiers
- B. Obtaining informed consent
- C. Placing the blood product with Ringer's lactate
- D. Staying with the client for the entire transfusion
Correct Answer: B
Rationale: Obtaining informed consent is critical as it ensures the client understands the procedure and risks, which is a priority before initiating a transfusion. Correctly identifying the client is also crucial but follows consent in priority if the facility requires it. Ringer's lactate is not used for blood transfusions, and staying for the entire transfusion is not necessary.
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A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medications, what action by the nurse is best?
- A. Give the client pain medication if it is time for another dose.
- B. Instruct the client not to request pain medication too early.
- C. Give the client a placebo instead of pain medication.
- D. Tell the client it is too early to have more pain medication.
Correct Answer: A
Rationale: Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it. The other options are judgmental and do not address the client's pain. Giving placebos is unethical.
A nurse is preparing to hang a blood transfusion. Which action is most important?
- A. Documenting the transfusion
- B. Placing the client in NPO status
- C. Checking the blood product label
- D. Putting on a pair of gloves
Correct Answer: D
Rationale: To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood, prioritizing infection control. Documentation is important but not the priority at this point. NPO status is not required, and checking the blood product label, while critical, is secondary to standard precautions like wearing gloves.
A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.)
- A. Argatroban (Argatroban)
- B. Bivalirudin (Angiomax)
- C. Clopidogrel (Plavix)
- D. Lepirudin (Refludan)
- E. Methylprednisolone (Solu-Medrol)
Correct Answer: A,B,D
Rationale: Argatroban, bivalirudin, and lepirudin are direct thrombin inhibitors used to treat HIT. Clopidogrel is an antiplatelet agent, and methylprednisolone is a steroid, neither used for HIT.
A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?
- A. Correctly identifying client using two identifiers
- B. Double-checking client and blood type information
- C. Placing the client on strict bedrest until the pain subsides
- D. Reviewing the client's medical record for known allergies
Correct Answer: B
Rationale: This client has a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type to confirm the error. Documentation occurs after the client is stable. Bedrest may not be needed, and allergies to medications or environmental items are not related.
A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority?
- A. Genetic testing
- B. Sperm banking
- C. Treatment options
- D. Lifestyle changes
Correct Answer: B
Rationale: All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of appropriate concern if the client is going to have radiation to the lower abdomen or pelvis.