A nurse is preparing to administer a blood transfusion to a client with significant blood loss. What is the nurse's most important action before starting the transfusion?
Check the client's blood pressure.
Verify the client's identification using two identifiers.
Assess the client's oxygen saturation level.
Obtain consent for the blood transfusion.
The Correct Answer is B
A) Incorrect. Checking the client's blood pressure is important but not the most critical action before starting a blood transfusion.
B) Correct. The most crucial step before administering any intervention, including a blood transfusion, is to verify the client's identification using two identifiers (e.g., name and date of birth or medical record number) to ensure the right blood is given to the right client.
C) Incorrect. While assessing the client's oxygen saturation is important, it is not the priority before starting a blood transfusion.
D) Incorrect. Obtaining consent for the blood transfusion is essential, but verifying the client's identification is more critical before administering the transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect. Gastric analysis is not commonly used to confirm the presence of blood in the stomach or identify the source of bleeding.
B) Incorrect. Abdominal ultrasound may be helpful in evaluating certain abdominal conditions but is not the primary test for diagnosing upper gastrointestinal bleeding.
C) Correct. Esophagogastroduodenoscopy (EGD) is a direct visualization procedure that uses a flexible endoscope to examine the esophagus, stomach, and duodenum. It allows for visualization of the source of bleeding and potential interventions like cauterization or sclerotherapy.
D) Incorrect. Stool culture is used to detect gastrointestinal infections but is not specific to diagnosing upper gastrointestinal bleeding.
Correct Answer is C
Explanation
A) Correct. Anticoagulant medication can interfere with the body's clotting mechanism, increasing the risk of bleeding.
B) Correct. A family history of bleeding disorders can be a risk factor for hemorrhage due to potential genetic predisposition.
C) Incorrect. Regular low-impact exercise is a positive lifestyle choice that helps maintain cardiovascular health and does not directly contribute to an increased risk of hemorrhage.
D) Correct. Recent major surgery can be a risk factor for hemorrhage due to potential surgical site bleeding or complications.
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