A nurse is preparing to administer a blood transfusion to a client with significant blood loss. What is the nurse's most important action before starting the transfusion?

Check the client's blood pressure.

Verify the client's identification using two identifiers.

Assess the client's oxygen saturation level.

Obtain consent for the blood transfusion.

Answer and Explanation

The Correct Answer is B

A) Incorrect. Checking the client's blood pressure is important but not the most critical action before starting a blood transfusion.

B) Correct. The most crucial step before administering any intervention, including a blood transfusion, is to verify the client's identification using two identifiers (e.g., name and date of birth or medical record number) to ensure the right blood is given to the right client.

C) Incorrect. While assessing the client's oxygen saturation is important, it is not the priority before starting a blood transfusion.

D) Incorrect. Obtaining consent for the blood transfusion is essential, but verifying the client's identification is more critical before administering the transfusion.

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Correct Answer is A

Explanation

A) Correct. In liver cirrhosis, the damaged liver may sequester platelets, leading to a decreased platelet count. However, an elevated platelet count (thrombocytosis) can occur as a compensatory response to decreased liver function and is a sign of an increased risk of hemorrhage due to poor clot formation.

B) Incorrect. Low prothrombin time (PT) indicates faster clotting and is not associated with an increased risk of hemorrhage.

C) Incorrect. Decreased ammonia levels are a positive finding in liver cirrhosis, as elevated ammonia levels are harmful to the brain.

D) Incorrect. Elevated liver enzymes are indicative of liver damage, but they do not directly impact the client's risk of hemorrhage.

A. "The doctor will remove a sample of my bone marrow for testing." B. "They will use a scope to look inside my stomach and intestines." C. "The nurse will check my blood pressure and heart rate during the procedure." D. "They will perform an ultrasound to see if there's any bleeding in my abdomen."

Correct Answer is A

Explanation

A) Correct. Bone marrow aspiration involves the removal of a small sample of bone marrow from the hip bone to assess the production of blood cells and identify potential causes of bleeding disorders.

B) Incorrect. The statement describes an esophagogastroduodenoscopy (EGD), which is not the procedure scheduled for this client.

C) Incorrect. Monitoring blood pressure and heart rate is essential during any procedure, but it is not specific to bone marrow aspiration.

D) Incorrect. An ultrasound is not relevant to a bone marrow aspiration procedure and is not used to assess bleeding disorders. It is typically used for imaging soft tissues and organs.

Questions

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A nurse is preparing to administer a blood transfusion to a client with significant blood loss. What is the nurse's most important action before starting the transfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with liver cirrhosis. Which assessment finding supports the client's increased risk of hemorrhage?

Correct Answer is A

Explanation

A client with suspected bleeding disorders is scheduled for a bone marrow aspiration. Which statement made by the client indicates a correct understanding of the procedure?

Correct Answer is A

Explanation

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