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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: play a crucial role in transplant rejection. They can recognize and attack foreign tissues, including transplanted organs, leading to rejection. This immune response is a significant concern in transplant medicine, and managing T cell activity is essential for the success of organ transplants.
Choice B reason: While anaphylaxis is an acute allergic reaction, it is more commonly associated with the release of histamines and other mediators from mast cells and basophils. can contribute to the severity of the reaction, but they are not the primary cells involved in anaphylaxis.
Choice C reason: Bacterial phagocytosis is primarily the function of phagocytes like neutrophils and macrophages. do not directly engage in phagocytosis but can activate other immune cells that do.
Choice D reason: Hay fever, or allergic rhinitis, involves an immune response to airborne allergens, with contributing to the development of symptoms by helping to produce IgE antibodies. However, the immediate symptoms of hay fever are more directly related to mast cell activation rather than activity.
Correct Answer is A
Explanation
Choice A reason: Right lower quadrant.
McBurney's point is located in the right lower quadrant of the abdomen, which is one-third of the distance from the anterior superior iliac spine to the umbilicus. This is the area where tenderness is most likely to be maximal in cases of acute appendicitis.
Choice B reason: Left lower quadrant
The left lower quadrant is not typically associated with appendicitis pain, as the appendix is located in the right lower quadrant of the abdomen.
Choice C reason: Right upper quadrant
The right upper quadrant is generally associated with other conditions such as gallbladder issues, not appendicitis.
Choice D reason: The left upper quadrant
The left upper quadrant is also not associated with appendicitis pain, as it is on the opposite side of the typical location of the appendix.
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