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.

Nursing Test Bank

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Correct Answer is B

Explanation

A. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow." This describes acute angle-closure glaucoma, not retinal detachment.

B. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye." Retinal detachment happens when the retina separates from its supporting tissues, including the blood vessels, leading to vision loss.

C. "Vision changes occur when the retina begins to break down and collect bits of debris." This describes age-related macular degeneration, not retinal detachment.

D. "Vision changes occur when the cloudy lens alters the passage of light through the eye." This describes cataracts, not retinal detachment.

A. Phlebotomist B. Assistive personnel C. Senior nursing student D. Oncology nurse

Correct Answer is D

Explanation

A. Phlebotomist - Phlebotomists are trained in drawing blood and handling specimens but are not typically trained to verify blood products for transfusion.

B. Assistive personnel - Assistive personnel (e.g., nursing assistants) do not have the required training or authority to verify blood products for transfusion.

C. Senior nursing student - Although a senior nursing student may have some clinical experience, they do not have the qualifications or the responsibility required for this critical safety task.

D. Oncology nurse - An oncology nurse is a registered nurse with specialized training and experience in administering blood products and managing the associated risks, making them qualified to double-check blood labels and patient identification.

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A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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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

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Explanation

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Correct Answer is D

Explanation

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