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 A
Explanation
A. "Eating a high fiber diet will reduce my risk for developing skin cancer." There is no evidence that a high-fiber diet specifically reduces the risk of skin cancer. This statement indicates a misunderstanding and a need for further teaching.
B. "I should check my skin monthly for any changes." Regular self-examinations are recommended to detect early signs of skin cancer.
C. "I should use sunscreen even on cloudy days." UV rays can penetrate clouds, so using sunscreen on cloudy days is an important preventive measure.
D. "I should avoid the use of tanning booths." Tanning booths increase the risk of skin cancer, so avoiding them is a correct preventive action.
Correct Answer is D
Explanation
A. Phlebotomist - Phlebotomists are trained in drawing blood and handling specimens but are not typically trained to verify blood products for transfusion.
B. Assistive personnel - Assistive personnel (e.g., nursing assistants) do not have the required training or authority to verify blood products for transfusion.
C. Senior nursing student - Although a senior nursing student may have some clinical experience, they do not have the qualifications or the responsibility required for this critical safety task.
D. Oncology nurse - An oncology nurse is a registered nurse with specialized training and experience in administering blood products and managing the associated risks, making them qualified to double-check blood labels and patient identification.
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