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 B
Explanation
A) Incorrect. While pain management is important, it is not the priority in the management of massive hemorrhage and hypovolemia.
B) Correct. The priority intervention for a client experiencing massive hemorrhage and hypovolemia is to initiate a blood transfusion to replace lost blood and improve oxygen-carrying capacity.
C) Incorrect. Emotional support is essential, but it is not the priority in the acute management of hemorrhage and hypovolemia.
D) Incorrect. Deep breathing exercises are not the priority when the client is experiencing massive hemorrhage and requires urgent interventions to stabilize their condition.
Correct Answer is C
Explanation
A) Incorrect. While monitoring the client's pain level is important, it is not the priority when managing postpartum hemorrhage.
B) Incorrect. While breastfeeding can help stimulate uterine contractions, it is not the priority when actively managing postpartum hemorrhage.
C) Correct. Assessing the client's uterine contractions is the priority when managing postpartum hemorrhage. Weak or ineffective contractions can contribute to excessive bleeding after childbirth.
D) Incorrect. While educating the client about contraceptive methods is essential for family planning, it is not the immediate priority when managing postpartum hemorrhage.
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