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: Infusing packed RBCs over 1 hour is typically too rapid for most patients and can increase the risk of adverse reactions, especially in those with cardiovascular compromise.

Choice B reason: A 2hour infusion may be appropriate in certain emergency situations where rapid correction of anemia is required, but it is not the standard practice for routine transfusions.

Choice C reason: A 3hour infusion is less commonly used and does not provide any specific advantage over the standard 4hour infusion time.

Choice D reason: The standard practice is to complete the transfusion of packed RBCs within 4 hours. This duration minimizes the risk of bacterial growth and transfusion reactions, as recommended by the American Society of Hematology and other clinical guidelines.

A. Acute pain B. Ecchymosis of the surrounding skin C. Increasing edema D. Diminishing distal pulse

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.

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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

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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