Author Question: The nurse initiates a blood transfusion for a client. What action should the nurse take next? 1. ... (Read 44 times)

mspears3 · **on:** Jul 23, 2018

The nurse initiates a blood transfusion for a client. What action should the nurse take next?

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 nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins?

1. Position the hand at heart level.
2. Stroke the vein.
3. Have the client clench and unclench the fist.
4. Slap the back of the client's hand.
5. Massage the vein.

olivia_paige29 · **Reply #1 on:** Jul 23, 2018

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, 3, 5
Rationale 1: The hand should be lower than the heart to dilate the vein.
Rationale 2: Stroking the vein helps to dilate the vein.
Rationale 3: Having the client clench and unclench the fist is a strategy used to help dilate a vein.
Rationale 4: Slapping the vein is contraindicated and may actually reduce venous filling.
Rationale 5: Massaging the vein helps with vein dilation.