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 D

Explanation

A. The first 2 min - This is too short a period to monitor effectively for transfusion reactions.

B. The final 2 min - Transfusion reactions are more likely to occur at the beginning of the transfusion rather than at the end.

C. The final 15 min - While it’s still important to monitor, reactions are most likely to be detected earlier in the infusion.

D. The first 15 min - Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for any signs of a reaction, such as fever, chills, rash, or difficulty breathing.

A. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow" B. Vision changes occur when retinal tissue pulls away from the blood vessels in the eye " C. Vision changes occur when the retina gins to breakdown and collect bits of debris D. Vision changes occur when the cloudy lens alters the passage of light through the eye”

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.

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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

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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