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

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: This choice is incorrect. Partial compensation would typically involve a change in PaCO2 to counterbalance the elevated bicarbonate, which is not observed here.

Choice B reason: This choice is incorrect. Respiratory acidosis is characterized by a low pH and an elevated PaCO2, which is not consistent with the given values.

Choice C reason: This choice is incorrect. Respiratory alkalosis would present with a low PaCO2 due to hyperventilation, which is not the case here.

Choice D reason: This is the correct choice. The elevated pH and HCO3 with a normal PaCO2 indicate metabolic alkalosis without respiratory compensation. Persistent vomiting can lead to loss of stomach acid, which causes metabolic alkalosis.

A. Serum creatinine 1.8 mg/dL B. Magnesium 2.0 mEq/L C. Blood urea nitrogen (BUN) 20 mg/dL D. Serum osmolality 290 mOsm/kg H2O

Correct Answer is A

Explanation

Choice A reason: Serum creatinine is a waste product from the normal breakdown of muscle tissue. A level of 1.8 mg/dL is higher than the normal range (0.61.2 mg/dL for females), indicating impaired kidney function and an increased risk of AKI.

Choice B reason: A magnesium level of 2.0 mEq/L is within the normal range (1.72.2 mEq/L) and does not typically indicate an increased risk of AKI.

Choice C reason: A BUN level of 20 mg/dL is within the normal range (720 mg/dL) and does not suggest an increased risk of AKI by itself.

Choice D reason: A serum osmolality of 290 mOsm/kg H2O is within the normal range (275295 mOsm/kg H2O) and does not indicate an increased risk of AKI.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of acute kidney injury (AKI). Which of the following findings should the nurse identify as indicating an increased risk of AKI?

Correct Answer is A

Explanation

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