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. Scatter rugs are present in the kitchen - Scatter rugs can cause tripping and slipping, posing a significant fall risk for someone with vision impairment.
B. Handrails are present in the bathroom - Handrails provide support and help prevent falls, making them a safety feature, not a risk.
C. Electrical cords are placed along the walls - This helps prevent tripping over cords, thus reducing fall risk.
D. Uses a microwave for cooking - A microwave is generally safer than a stove as it reduces the risk of burns and fires, making it a safety feature.
Correct Answer is A
Explanation
A. Endolymph fluid provides protection to the structures of the inner ear. - Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance.
B. Sanguineous fluid provides protection to the structures of the inner ear - Sanguineous fluid refers to blood or fluid containing blood. It is not present in the inner ear.
C. Aqueous humor provides protection to the structures of the inner ear - Aqueous humor is the fluid found in the eye, not the ear.
D. Vitreous humor provides protection to the structures of the inner ear - Vitreous humor is found in the eye, not the ear.
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