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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Incorrect. A complete blood count (CBC) provides information about the client's red blood cells, white blood cells, and platelets, but it does not directly assess clotting function.

B) Incorrect. Serum electrolytes help assess the body's fluid balance and various organ functions, but they do not specifically indicate clotting function.

C) Correct. Prothrombin time (PT) is a measure of the time it takes for the blood to clot, primarily assessing the function of the extrinsic pathway of coagulation. It is an essential test in evaluating clotting disorders.

D) Incorrect. Blood glucose level is not directly related to clotting function and is more indicative of a client's metabolic status.

A. "Avoid participating in contact sports." B. "Keep the home environment cold to prevent vasodilation." C. "Use electric razors for shaving to prevent cuts." D. "Take aspirin daily to reduce the risk of clot formation."

Correct Answer is C

Explanation

A) Incorrect. Avoiding contact sports is a relevant safety measure for some individuals with bleeding disorders, but it is not the priority in preventing cuts and bleeding at home.

B) Incorrect. While keeping the home environment cool may be helpful for some individuals with certain bleeding disorders, it is not the primary safety measure.

C) Correct. Using electric razors for shaving can prevent cuts and reduce the risk of bleeding in clients with bleeding disorders.

D) Incorrect. Taking aspirin daily is not recommended for clients with bleeding disorders as it can increase the risk of bleeding due to its antiplatelet effects.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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