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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Impaired skin integrity - While the patient does have skin issues due to ulcerations, the root cause is impaired perfusion. Addressing the impaired tissue perfusion will help improve skin integrity.

B. Alteration in activity tolerance - Although the patient might experience reduced activity tolerance due to the heaviness and discomfort, it is not as critical as ensuring adequate tissue perfusion.

C. Impaired tissue perfusion - This diagnosis is the priority because varicose veins and ulcerations with lower extremity edema suggest that there is poor blood flow to the tissues, which can lead to further complications such as worsening ulcerations and potential infection. Effective tissue perfusion is critical to healing and preventing further deterioration.

D. Alteration in body image - This is a valid concern for the patient but is not as immediate or life-threatening as impaired tissue perfusion and the potential for complications from poor circulation.

A. Sleep on the abdomen to facilitate wound healing. B. Bend at the waist to pick objects up from the floor. C. Notify the surgeon if white drainage develops on the eyelids. D. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.

Correct Answer is D

Explanation

A. Sleep on the abdomen to facilitate wound healing: Clients are usually advised to avoid sleeping on the side of the operated eye or on the abdomen to prevent pressure on the eye.

B. Bend at the waist to pick objects up from the floor: Bending at the waist can increase intraocular pressure, which is not advisable post-surgery.

C. Notify the surgeon if white drainage develops on the eyelids: White drainage may be a sign of normal healing or minor irritation; however, yellow or green discharge would be more concerning for infection.

D. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Lifting heavy objects can increase intraocular pressure and potentially disrupt the healing process after cataract surgery. The client should avoid such activities to promote proper healing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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