A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client?

Confirm the provider's prescription matches the number on the blood component.

Match the client's blood type with the type and cross match specimen.

Ask the client to state his blood type and the date of the blood donation.

Ensure that the client's identification and matches the number on the blood unit.

Answer and Explanation

The Correct Answer is D

A. Confirm the provider's prescription matches the number on the blood component: While verifying the provider’s prescription is important, it does not confirm the identity of the client receiving the blood. Client identification must be confirmed directly at the bedside.

B. Match the client's blood type with the type and cross match specimen: Verifying blood type compatibility is essential for transfusion safety, but it does not replace proper client identification. Misidentification could still occur if other verification steps are skipped.

C. Ask the client to state his blood type and the date of the blood donation: Clients may not reliably recall these details, and relying solely on self-report is unsafe. Proper identification requires objective verification using official identification methods.

D. Ensure that the client's identification matches the number on the blood unit: Correct client identification is achieved by comparing the client’s ID band information with the blood unit number and labels. This step is the primary safeguard to prevent transfusion errors and ensure the right client receives the correct blood product.

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Free Nursing Study Resources

Correct Answer is ["A","D","E","F","H","I"]

Explanation

Rationale for correct choices

• Gastrointestinal: Persistent nausea and frequent vomiting in early pregnancy can lead to dehydration, electrolyte imbalance, and malnutrition. Hypoactive bowel sounds and dry mucous membranes further suggest fluid deficit and possible electrolyte disturbances. Reporting these findings allows the provider to assess severity and initiate interventions.

• Genitourinary: Oliguria and dark, concentrated urine indicate potential dehydration, which can exacerbate nausea and vomiting and compromise kidney function. Early reporting is critical to prevent complications such as acute kidney injury.

• Cardiovascular: The relative hypotension as compared to the baseline blood pressuremay reflect compensatory tachycardia due to dehydration or volume depletion. These vital sign changes warrant reporting because they help the provider assess hemodynamic stability and guide fluid management.

Rationale for incorrect findings:

• Constipation and abdominal palpation without tenderness: Mild constipation without abdominal tenderness is common in early pregnancy due to hormonal changes and is not immediately concerning. It can be managed with dietary fiber, hydration, and gentle activity.

• No edema: The absence of edema indicates no overt fluid retention or preeclampsia at this stage. While monitoring continues, this finding does not require urgent reporting.

A. Trim the fat from red meat prior to cooking. B. Give the child hot foods to reduce the sense of fullness. C. Administer pancreatic enzymes 30 min after meals. D. Provide a diet high in protein and calories.

Correct Answer is D

Explanation

A. Trim the fat from red meat prior to cooking: Children with cystic fibrosis (CF) require a high-calorie, high-fat diet due to malabsorption from pancreatic insufficiency. Trimming fat would reduce caloric intake and fat-soluble vitamin absorption, which is contraindicated in CF nutritional management.

B. Give the child hot foods to reduce the sense of fullness: Food temperature does not significantly affect satiety or nutrient absorption in CF. The focus should be on calorie density and nutrient content rather than temperature, as energy needs are significantly increased in these children.

C. Administer pancreatic enzymes 30 min after meals: Pancreatic enzyme replacement therapy should be given with meals or immediately before eating to optimize digestion of fats, proteins, and carbohydrates. Administering enzymes after meals would reduce nutrient absorption and worsen malnutrition.

D. Provide a diet high in protein and calories: Children with CF have increased metabolic demands and impaired nutrient absorption, making a high-calorie, high-protein diet essential to support growth, maintain weight, and compensate for malabsorption.

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Body System	Findings
Gastrointestinal	Client states, "I'm nauseated all the time. I vomit a few times a day, too." Client states, "I've been a little constipated, but it's not too bad." Abdomen without tenderness on palpation. Bowel sounds hypoactive. Oral mucous membranes sticky.
Genitourinary	Also reports they are urinating less and that urine is dark yellow and odorous. Clean-catch urine specimen obtained. Urine noted to be dark yellow and concentrated
Cardiovascular	Heart rate regular. No edema. Heart rate 92/min Blood pressure 102/66 mm Hg

A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","D","E","F","H","I"]

Explanation

A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the following instructions should the nurse plan to include?

Correct Answer is D

Explanation

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