A client's low hemoglobin level has necessitated transfusion of packed red blood cells. Prior to administration, which action should the nurse perform?
Assess the client's vital signs to establish baselines.
Ensure that the client has granted verbal consent for transfusion.
Have the client identify the blood type in writing
Facilitate insertion of a central venous catheter for rapid infusion.
The Correct Answer is A
A. Assess the client's vital signs to establish baselines: Obtaining baseline vital signs is essential before transfusion to detect any changes that may indicate a reaction. Comparing pre- and post-transfusion measurements helps identify fever, hypotension, or tachycardia early. This assessment is a standard safety measure to monitor for adverse events.
B. Ensure that the client has granted verbal consent for transfusion: While informed consent is required, it must already be documented, not just verbal. The nurse verifies consent, but this is not the immediate clinical action needed just prior to starting the transfusion. Documentation of consent ensures legal and ethical compliance.
C. Have the client identify the blood type in writing: Blood type verification is performed by comparing the blood product with the client’s medical record and wristband, not by having the client write it. Client identification is essential, but written self-report is not reliable for safety checks. Correct matching is confirmed by the healthcare team.
D. Facilitate insertion of a central venous catheter for rapid infusion: Central line placement is not required for routine PRBC transfusion unless rapid or large-volume resuscitation is anticipated. Most transfusions are safely administered via peripheral IV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Decreased seizure activity: Mannitol does not have anticonvulsant properties. Seizure activity is managed with antiepileptic medications, not osmotic diuretics. Monitoring for seizure reduction is not a therapeutic goal of mannitol.
B. Decreased urinary output: Mannitol is an osmotic diuretic, which increases urine output to remove fluid from tissues, including the brain. A decrease in urine output would indicate a problem with the drug’s effectiveness or renal function.
C. Decreased cerebral metabolism: Mannitol does not directly reduce cerebral metabolic rate. Its primary action is fluid removal, not altering neuronal metabolism or oxygen consumption.
D. Decreased cerebral edema: Mannitol reduces intracranial pressure by drawing water out of edematous brain tissue into the intravascular space. This decrease in cerebral edema is the expected therapeutic effect and is monitored through neurologic assessments and ICP measurements.
Correct Answer is A
Explanation
A. hemorrhage from esophageal varices: Portal hypertension increases pressure in the portal venous system, leading to esophageal varices that can rupture. Massive bleeding from varices is life-threatening and requires immediate intervention, making this the most critical complication to monitor.
B. liver abscess: Liver abscesses can occur in clients with liver disease but are less immediately life-threatening than variceal bleeding. They develop over time and usually present with fever and localized pain rather than sudden hemorrhage.
C. hemorrhage from duodenal diverticulitis: Duodenal diverticulitis is rare and not a common complication of portal hypertension. While it can cause bleeding, it is not the primary life-threatening concern in this population.
D. small bowel obstruction: Small bowel obstruction is not directly associated with portal hypertension. Although it can cause significant complications, it is not an immediate risk in these clients.
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