The nurse reviews the entries in the medical record. Exhibits The nurse is preparing the client for a blood transfusion, which of the following actions should the nurse take? Select all that apply.

Rationale for correct choices: Insert a large-bore IV catheter: A large-bore IV (18–20 gauge) is necessary to allow rapid administration of blood products and reduce hemolysis of red blood cells during transfusion. This ensures safe and effective delivery of the blood components. Witness the client signing a consent for transfusion: Informed consent is required before initiating a blood transfusion. The nurse ensures that the client understands the purpose, risks, and potential complications, and witnesses the signing to meet legal and ethical standards. Have a second nurse confirm the information on the blood lab: Verifying the blood type, crossmatch, and client identifiers with a second nurse reduces the risk of transfusion errors and ensures patient safety before starting the transfusion. Rationale for incorrect choices: Explain to the client that transfusion reactions are not serious: Transfusion reactions can be serious, including hemolytic reactions, febrile reactions, or allergic responses. The nurse should educate the client on the potential risks and signs of a reaction rather than minimizing them. Flush the transfusion tubing with dextrose 5% in water: Blood products should only be administered with 0.9% sodium chloride (normal saline). Flushing with dextrose or other solutions can cause hemolysis and compromise the safety of the transfusion.