A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
Hemoglobin level
Fluid intake
Temperature
Skin color
The Correct Answer is C
A. Hemoglobin level: While knowing the hemoglobin level helps determine the need for the transfusion, it is generally assessed and ordered by the provider before the transfusion is prescribed. It is important information but not the most immediate data required directly before administering the PRBCs.
B. Fluid intake: Monitoring fluid balance is important, especially in clients at risk for fluid overload, but it is not as immediately critical as temperature in detecting potential reactions to the transfusion.
C. Temperature: A baseline temperature is crucial to monitor for febrile reactions during the transfusion. Any significant rise in temperature can signal a transfusion reaction, which requires immediate intervention.
D. Skin color: Skin color can provide information on overall oxygenation and perfusion but is not as specific or immediately useful as temperature for monitoring for transfusion reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I need something for the pain in my eye. I can't stand it." Severe pain after cataract surgery is unusual and could indicate complications such as increased intraocular pressure or infection. This should be reported immediately to the provider for further evaluation.
B. "It’s hard to see with a patch on one eye. I'm afraid of falling": This is a common concern and relates to mobility safety, not a sign of a surgical complication.
C. "My eye really itches, but I'm trying not to rub it.": Itching can be a normal response post-surgery due to healing. Patients should avoid rubbing the eye, and this does not necessarily indicate a complication.
D. "The bright light in this room is really bothering me.": Photophobia or sensitivity to light can be common postoperatively and is usually not a sign of a serious issue.
Correct Answer is A
Explanation
A. "Eating a high fiber diet will reduce my risk for developing skin cancer." There is no evidence that a high-fiber diet specifically reduces the risk of skin cancer. This statement indicates a misunderstanding and a need for further teaching.
B. "I should check my skin monthly for any changes." Regular self-examinations are recommended to detect early signs of skin cancer.
C. "I should use sunscreen even on cloudy days." UV rays can penetrate clouds, so using sunscreen on cloudy days is an important preventive measure.
D. "I should avoid the use of tanning booths." Tanning booths increase the risk of skin cancer, so avoiding them is a correct preventive action.
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