A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

Hemoglobin level

Fluid intake

Temperature

Skin color

Answer and Explanation

The Correct Answer is C

A. Hemoglobin level: While knowing the hemoglobin level helps determine the need for the transfusion, it is generally assessed and ordered by the provider before the transfusion is prescribed. It is important information but not the most immediate data required directly before administering the PRBCs.

B. Fluid intake: Monitoring fluid balance is important, especially in clients at risk for fluid overload, but it is not as immediately critical as temperature in detecting potential reactions to the transfusion.

C. Temperature: A baseline temperature is crucial to monitor for febrile reactions during the transfusion. Any significant rise in temperature can signal a transfusion reaction, which requires immediate intervention.

D. Skin color: Skin color can provide information on overall oxygenation and perfusion but is not as specific or immediately useful as temperature for monitoring for transfusion reactions.

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Correct Answer is C

Explanation

A. Impaired skin integrity - While the patient does have skin issues due to ulcerations, the root cause is impaired perfusion. Addressing the impaired tissue perfusion will help improve skin integrity.

B. Alteration in activity tolerance - Although the patient might experience reduced activity tolerance due to the heaviness and discomfort, it is not as critical as ensuring adequate tissue perfusion.

C. Impaired tissue perfusion - This diagnosis is the priority because varicose veins and ulcerations with lower extremity edema suggest that there is poor blood flow to the tissues, which can lead to further complications such as worsening ulcerations and potential infection. Effective tissue perfusion is critical to healing and preventing further deterioration.

D. Alteration in body image - This is a valid concern for the patient but is not as immediate or life-threatening as impaired tissue perfusion and the potential for complications from poor circulation.

A. Elevate the limb and apply ice. B. Apply a tourniquet just below the elbow. C. Apply direct pressure over the wound. D. Clean the wound.

Correct Answer is C

Explanation

A. Elevate the limb and apply ice. Elevating the limb and applying ice can help reduce blood flow to the area and minimize swelling. However, it is not the immediate priority in managing active, profuse bleeding.

B. Apply a tourniquet just below the elbow. A tourniquet should be a last resort due to the risk of cutting off blood flow and potential limb damage. It's typically used in life-threatening situations where other methods fail to control bleeding.

C. Apply direct pressure over the wound. The immediate priority for controlling profuse bleeding is to apply direct pressure to the wound to stop or reduce the bleeding. This is a standard first-line intervention in hemorrhage management.

D. Clean the wound. Cleaning the wound is important to prevent infection, but it is not the first priority when dealing with active, profuse bleeding.

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A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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