A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. Which of the following should the nurse use as the priority source of verification?
Medication administration record
Identification wristband
Order sheet
Chart
The Correct Answer is B
Choice A reason: The medication administration record is an important document, but it is not the primary source for verification before administering blood products. It is used to record the administration after the fact.
Choice B reason: The identification wristband is the priority source for verification. It contains the client's essential information, such as name and hospital ID, which must match the blood product label to ensure patient safety⁸.
Choice C reason: The order sheet contains the physician's orders, which is crucial for verifying what has been prescribed but is secondary to the identification wristband for the actual administration process.
Choice D reason: The chart contains a comprehensive record of the client's medical history and care but is not the primary source for verification when administering blood products.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Establishing short-term, realistic goals is important, but it should come after assessing the client's current knowledge. Goals should be tailored to the individual's needs and understanding.
Choice B reason: Assessing the client's current knowledge about managing diabetes is crucial as the first step. This allows the nurse to identify any gaps in understanding and to provide education that is specific to the client's needs.
Choice C reason: Providing access to a video about diabetes can be a useful educational tool, but it should not be the first action. The content of the video may not address the client's specific questions or misconceptions.
Choice D reason: Evaluating the effectiveness of the client's admission teaching plan is an ongoing process and should be done after initial education and interventions have been provided.
Correct Answer is B
Explanation
Choice A reason: Pain is a common postoperative symptom and should be managed appropriately. However, it is not typically considered a priority over other complications that can have more immediate and severe consequences.
Choice B reason: Hemorrhage is a significant risk after TURP and can be life-threatening. It is considered a priority because active bleeding can lead to shock and requires immediate intervention.
Choice C reason: Infection is a potential complication after any surgery, including TURP. While important to monitor for, it is generally not as immediately life-threatening as hemorrhage.
Choice D reason: Urinary retention can occur after TURP, but it is often anticipated and managed with the placement of a urinary catheter. It is a concern but not the highest priority immediately following surgery.
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