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 C
Explanation
Choice A reason: The blood should not be infusing for 5 hours as transfusions of packed RBCs should be completed within 2 to 4 hours to minimize the risk of bacterial growth and transfusion reactions.
Choice B reason: Medications should not be administered through the same IV line as blood products due to the risk of reactions and interactions.
Choice C reason: The packed RBCs are indeed connected by Tubing to normal saline, which is used to keep the line open and prevent clotting.
Choice D reason: The drip chamber should not be filled completely with blood as it is necessary to monitor the drip rate and to ensure that air does not enter the line.
Correct Answer is D
Explanation
Choice A reason: Humidifying the client's room can help maintain mucous membrane integrity and prevent respiratory infections, which is crucial for a client with a low WBC count.
Choice B reason: Replacing the water in flower vases daily can prevent the growth of bacteria, reducing the risk of infection for an immunocompromised client.
Choice C reason: Cleaning dentures in a denture cup is a standard infection control practice that helps maintain oral hygiene and prevent infections.
Choice D reason: Serving cooked fruit with meals reduces the risk of transmitting infections that can be associated with raw fruits, which is important for a client with neutropenia.
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