A student nurse is helping a registered nurse with a blood ...

[audragclark]

A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.)
 
  a. Hanging the blood product using normal saline and a filtered tubing set
  b. Taking a full set of vital signs prior to starting the blood transfusion
  c. Telling the client someone will remain at the bedside for the first 5 minutes
  d. Using gloves to start the client's IV if needed and to handle the blood product
  e. Verifying the client's identity, and checking blood compatibility and expiration time

Question 2

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
 
  a. Assist with oral hygiene using a firm toothbrush.
  b. Give the client an enema if he or she is constipated.
  c. Help the client choose soft foods from the menu.
  d. Shave the male client with an electric razor.
  e. Use a lift sheet when needed to re-position the client.

[zenzy]

Answer to Question 1

ANS: A, B, D
Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 30 minutes of the transfusion. Two registered nurses must verify the client's identity and blood compatibility.

Answer to Question 2

ANS: C, D, E
This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft-bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client.