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 B

Explanation

A. "My son will have to grow a beard." Growing a beard is irrelevant to managing hemophilia and preventing bleeding.

B. "My son will have to avoid contact sports." Avoiding contact sports is essential for children with hemophilia to reduce the risk of trauma and bleeding episodes due to their clotting factor deficiency.

C. "My son will have to avoid fresh foods such as fruit in his diet." Fresh foods like fruits do not pose a bleeding risk for hemophilia; dietary restrictions are generally unnecessary in managing this condition.

D. "My son will always have to live near a major hospital."While proximity to a healthcare facility can be helpful in emergencies, this is not a requirement for managing hemophilia, nor does it directly prevent bleeding episodes.

A. Activity intolerance related to tissue hypoxia B. Ineffective airway clearance related to dyspnea. C. Risk for infection related to reduction in white blood cells (WBCs) D. Chronic pain related to bone marrow dysfunction

Correct Answer is A

Explanation

A. Activity intolerance related to tissue hypoxia: Pernicious anemia leads to a decrease in the body’s ability to carry oxygen due to a lack of intrinsic factor and subsequent vitamin B12 deficiency, resulting in tissue hypoxia. This can cause fatigue and activity intolerance as the body struggles to meet its oxygen demands.

B. Ineffective airway clearance related to dyspnea: Dyspnea may occur, but ineffective airway clearance is not directly related to pernicious anemia, as this condition primarily affects oxygen transport, not the airway.

C. Risk for infection related to reduction in white blood cells (WBCs): Pernicious anemia primarily affects red blood cells due to vitamin B12 deficiency; it does not typically lead to a reduction in white blood cells.

D. Chronic pain related to bone marrow dysfunction: While bone marrow may be affected in some anemias, chronic pain is not a typical symptom of pernicious anemia, and bone marrow dysfunction is not usually present.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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