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 B

Explanation

A. Keep family members aware of his condition: While important, keeping family informed is not as directly impactful on the client’s emotional support as direct interaction with the client.

B. Talk with the client during wound care. Talking with the client during wound care can help to establish a trusting relationship, provide emotional support, and help the client cope with the pain and stress associated with burn treatment.

C. Rotate nursing staff so he can have varied interactions: Continuity of care is often more comforting to clients than having varied interactions.

D. Assign assistive personnel to keep his room neat and clean: This task is important for infection control but does not directly provide emotional support.

A. Wash with plain soap and water. B. sit in the sun for 10 min per day. C. Apply moist heat. D. Apply hydrating lotions.

Correct Answer is D

Explanation

A. "Wash with plain soap and water." While cleanliness is important, plain soap can be drying and irritating. Gentle cleansing is better, using products that do not strip the skin of natural oils.

B. "Sit in the sun for 10 minutes per day." Sun exposure can exacerbate radiation dermatitis and should be avoided. The skin needs protection from additional UV damage.

C. "Apply moist heat." Moist heat can further irritate already sensitive skin and is not recommended for treating radiation-induced skin reactions.

D. "Apply hydrating lotions." Hydrating lotions help to soothe and moisturize the skin, promoting healing and alleviating dryness and scaling caused by radiation treatment. Use products specifically recommended for sensitive or radiated skin.

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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

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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