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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Acute pain is expected with a fracture but does not specifically indicate impaired venous return.
Choice B reason: Ecchymosis, or bruising, can occur with a fracture due to bleeding into the tissue but is not a direct indicator of venous return issues.
Choice C reason: Increasing edema is a sign of impaired venous return as it indicates a buildup of fluid in the tissues, which can occur if the veins are not effectively returning blood to the heart.
Choice D reason: A diminishing distal pulse could indicate arterial impairment rather than venous return issues.
Correct Answer is ["A","B","C"]
Explanation
Choice A: Apply heat for 10 minutes every hour
Applying heat can help to relax the muscles and relieve tension, which can reduce pain. Heat therapy increases blood flow, which can aid in healing and reduce stiffness.
Choice B: Sleep in a side lying position with flexed knees
Sleeping in a side-lying position with flexed knees can help to maintain the natural curve of the spine and reduce strain on the back muscles. It's also recommended to use a pillow between the knees for additional support.
Choice C: Avoid prolonged sitting
Prolonged sitting can put pressure on the discs in your lower back and cause or exacerbate pain. It's recommended to take regular breaks to stand up and move around.
Choice D: Use padded shoe insoles
While padded shoe insoles can provide comfort and support for some people, there's no strong evidence to suggest that they can help to prevent or relieve back pain.
Choice E: Sleep on a soft mattress
Contrary to popular belief, a soft mattress may not be the best choice for people with back pain. A mattress that's too soft can cause your back to sink into the mattress, leading to poor sleep posture and discomfort. It's generally recommended to choose a mattress that provides good support and maintains the spine's natural alignment.
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