A nurse receives change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?
Inform the charge nurse of the need to reassign the client's care.
Obtain informed consent from the client for the blood transfusion.
Delegate the client's care to an RN.
Access the nursing information system for guidelines about blood transfusions.
The Correct Answer is B
A. Informing the charge nurse of the need to reassign the client’s care is unnecessary unless the nurse is unable to provide safe and competent care for the transfusion.
B. Obtaining informed consent is essential before a blood transfusion to ensure the client is aware of the procedure's purpose, benefits, and potential risks.
C. Delegating the client's care to another RN may be appropriate if the nurse lacks competence with transfusions, but obtaining consent is a priority.
D. Accessing the nursing information system for transfusion guidelines is helpful, but obtaining consent takes precedence before proceeding with the transfusion.
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Correct Answer is A
Explanation
A. Reviewing evidence-based literature is essential to understand best practices in shift reporting and can inform the development of effective interventions. This foundational step helps ensure that any proposed changes are supported by research and proven methods.
B. While organizing a task force can be beneficial, it should occur after understanding the current best practices, as the task force's efforts would be better guided with existing evidence.
C. Creating a new reporting process without first gathering information or reviewing best practices may result in ineffective or unnecessary changes.
D. Developing a strategy to alert nurses is important, but it should be based on informed decisions derived from literature and data analysis, which should come first.
Correct Answer is D
Explanation
A. While it's a good idea to rotate nonperishable food items to ensure freshness, the recommendation is typically to check them periodically rather than replace them annually, making this statement less accurate for disaster preparedness.
B. Having a backup supply of nonprescription medications is beneficial, but this is not a primary recommendation for disaster preparedness and may not specifically apply to all older adults.
C. The standard recommendation is to stock at least 1 gallon of water per person per day, not 2 liters, which is less than the recommended amount for hydration and other needs during emergencies.
D. Gathering enough supplies to last for 2 weeks is an essential component of disaster preparedness, especially for older adults who may have specific health needs and may not have easy access to supplies during a disaster.