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 B
Explanation
A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not an escharotomy.
B. "Large incisions will be made in the eschar to improve circulation." An escharotomy involves making large incisions through the eschar (the tough, leathery scab or crust that forms over a severely burned area) to relieve pressure and improve blood flow to the affected area. This procedure is often necessary to prevent complications such as compartment syndrome and to enhance circulation in burn patients.
C. "The procedure involves placing the client into a shower and removing the dead tissue.": This describes debridement, not an escharotomy.
D. "Dead tissue will be non-surgically removed.": Non-surgical removal of dead tissue is debridement, not an escharotomy, which is a surgical procedure.
Correct Answer is B
Explanation
A. Consume foods high in potassium: Potassium is important for ear health, but there is no direct evidence that high-potassium foods alone reduce the risk of hearing loss.
B. Avoid smoking tobacco products: Smoking is associated with an increased risk of hearing loss due to its negative effects on blood flow to the cochlea and the auditory nerve. Avoiding smoking can reduce the risk of hearing damage.
C. Increase oral intake of water: While staying hydrated is good for overall health, it does not specifically impact hearing loss risk.
D. Limit alcohol to two drinks daily: Excessive alcohol consumption can affect hearing, but moderation is not directly associated with preventing hearing loss as effectively as avoiding smoking.
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