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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is B
Explanation
A. Check the client's vital signs. While vital signs are important for overall assessment, the immediate priority when faced with wound dehiscence is to protect the wound and prevent further contamination or damage.
B. Cover the wound with a moist, sterile gauze dressing. The first priority is to cover the wound with a moist, sterile dressing to protect it from infection and to manage the drainage. This helps in creating a barrier to prevent contamination and supports the wound environment for healing.
C. Assess the client's pain level. Pain assessment is important but not the immediate priority in this case. Managing the wound and preventing further complications is more critical.
D. Obtain a culture and sensitivity of the wound drainage. While obtaining a culture is important to identify any infection, it is not the first action. Protecting the wound from further contamination comes first.
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