After initiating a blood transfusion for a client, the nurse ...

[olgavictoria]

After initiating a blood transfusion for a client, the nurse should now:
 
  1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion.
  2. Assign the UAP to sit with the client for 15 minutes.
  3. Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate.
  4. Return to the room and take a set of vital signs in 15 minutes.

Question 2

The client who has an IV with an intermittent infusion lock in place wishes to shower. What action should be taken by the nurse?
 
  1. Have the UAP discontinue the lock.
  2. Cover the lock with an occlusive dressing.
  3. Place a piece of cloth tape under the lock, wrapping the top in a U shape.
  4. Tell the client that a bed bath is necessary until the IV is discontinued.

[DylanD1323]

Answer to Question 1

Correct Answer: 1
Rationale 1: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion.
Rationale 2: The nurse cannot delegate this assessment to the UAP.
Rationale 3: The client should be advised of reactions to report, but this self-reporting is more indicated after the nurse is no longer in constant attendance.
Rationale 4: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. The nurse cannot delegate this assessment to the UAP.

Answer to Question 2

Correct Answer: 2
Rationale 1: UAP cannot discontinue the lock.
Rationale 2: The client can shower if the lock is covered with an occlusive dressing.
Rationale 3: Cloth tape will not protect the lock.
Rationale 4: The client can shower if the lock is covered with an occlusive dressing.

[olgavictoria]

Thanks

[DylanD1323]

Welcome