A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?

Skin color

Temperature

Hemoglobin level

Fluid intake

Answer and Explanation

The Correct Answer is B

A. Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.

B. Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.

C. Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.

D. Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.

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Correct Answer is ["1610"]

Explanation

Solution:

Convert ounces to milliliters (1 oz = 30 mL):
- Coffee: 8 oz × 30 mL = 240 mL
- Juice: 3 oz × 30 mL = 90 mL
- Soda: 12 oz × 30 mL = 360 mL
Calculate water intake:
- Initial pitcher: 800 mL
- Remaining: 200 mL
- Water intake = 800 mL - 200 mL = 600 mL
Calculate IV fluids intake:
- IV rate: 40 mL/hr
- Time: 8 hours
- IV fluids = 40 mL/hr × 8 hrs = 320 mL
Total intake:
- 240 mL (coffee) + 90 mL (juice) + 360 mL (soda) + 600 mL (water) + 320 mL (IV) = 1610 mL

Answer: 1610 mL

A. Intense abdominal pain B. Respiratory depression C. Dyspnea on exertion D. Bradycardia

Correct Answer is C

Explanation

A. Intense abdominal pain: While abdominal pain may occur in some conditions related to anemia, it is not a typical finding in anemia due to blood loss.

B. Respiratory depression: Respiratory depression is not commonly associated with anemia and would more likely indicate issues with central nervous system depression or drug side effects.

C. Dyspnea on exertion: Dyspnea on exertion is common in clients with anemia because of the decreased oxygen-carrying capacity of the blood, leading to tissue hypoxia. Anemia results in decreased hemoglobin levels, reducing the body’s ability to deliver adequate oxygen, particularly during physical activity.

D. Bradycardia: Anemia typically causes tachycardia (increased heart rate) rather than bradycardia, as the body compensates for low oxygen levels by increasing cardiac output.

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A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1610"]

Explanation

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Correct Answer is C

Explanation

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