A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. Which of the following should the nurse use as the priority source of verification?

Medication administration record

Identification wristband

Order sheet

Chart

Answer and Explanation

The Correct Answer is B

Choice A reason: The medication administration record is an important document, but it is not the primary source for verification before administering blood products. It is used to record the administration after the fact.

Choice B reason: The identification wristband is the priority source for verification. It contains the client's essential information, such as name and hospital ID, which must match the blood product label to ensure patient safety⁸.

Choice C reason: The order sheet contains the physician's orders, which is crucial for verifying what has been prescribed but is secondary to the identification wristband for the actual administration process.

Choice D reason: The chart contains a comprehensive record of the client's medical history and care but is not the primary source for verification when administering blood products.

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Correct Answer is C

Explanation

Choice A reason: While excessive alcohol consumption is a well known cause of liver cirrhosis, it is not typically associated with biliary cirrhosis1.

Choice B reason: Hepatotoxic medications can lead to liver damage, but they are not the primary cause of biliary cirrhosis1.

Choice C reason: Obstruction of the bile duct is a direct cause of biliary cirrhosis, as it can lead to bile accumulation and liver damage1.

Choice D reason: Hepatitis C can cause liver cirrhosis, but it is not a direct cause of biliary cirrhosis1

A. Elevated B. Stage 1 hypertension C. Stage 2 hypertension D. Normal

Correct Answer is A

Explanation

Choice A reason: A blood pressure reading of 124/79 mm Hg is considered elevated. The normal range for blood pressure is less than 120/80 mm Hg. Elevated blood pressure is when readings consistently range from 120129 systolic and less than 80 mm Hg diastolic.

Choice B reason: Stage 1 hypertension is defined by a systolic blood pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg. The client's blood pressure does not fall into this category.

Choice C reason: Stage 2 hypertension is characterized by a systolic blood pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher. The client's blood pressure is below these levels.

Choice D reason: A normal blood pressure reading is typically below 120/80 mm Hg. Although the client's diastolic pressure is within the normal range, the systolic pressure is above normal, thus it does not qualify as a normal blood pressure reading.

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A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. Which of the following should the nurse use as the priority source of verification?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about the causes of biliary cirrhosis. Which of the following should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/79 mm Hg places him in which of the following categories?

Correct Answer is A

Explanation

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