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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Correct Answer is B

Explanation

A. "The client was intubated without complications.": While this information can be relevant, it is more pertinent to include in the PACU hand-off only if intubation or airway management had ongoing implications. Routine, uncomplicated intubation is less critical than current clinical status and intraoperative events.

B. "The estimated blood loss was 250 milliliters.": Reporting estimated blood loss is essential for continuity of care, as it informs the receiving nurse about the client’s fluid status, potential for anemia, and need for ongoing monitoring or interventions. This is a key safety and clinical detail in the hand-off report.

C. "There was a total of 10 sponges used during the procedure.": While sponge count is important intraoperatively to prevent retained surgical items, it is typically documented in the surgical record and does not usually impact post-anesthesia care unless discrepancies exist.

D. "The client is a member of the board of directors.": Personal information unrelated to the client’s clinical care is not appropriate to include in a hand-off report. The focus should remain on pertinent medical, surgical, and recovery information.

A. "Of course, I will heat that up for you." B. "Why are you eating seaweed soup?" C. "The hospital food is more nutritious for you." D. "Does the doctor know that you are eating that?"

Correct Answer is A

Explanation

A. "Of course, I will heat that up for you.": Supporting the client’s cultural practices and dietary preferences promotes comfort, maternal satisfaction, and positive breastfeeding experiences. Seaweed soup is generally safe for postpartum consumption and does not pose a risk to the breastfeeding newborn, making this response culturally sensitive and appropriate.

B. "Why are you eating seaweed soup?": Asking this in a questioning or judgmental tone can be perceived as dismissive of cultural practices and may damage the therapeutic nurse-client relationship. It does not provide supportive guidance or education.

C. "The hospital food is more nutritious for you.": While hospital meals are designed to meet general nutritional needs, imposing them over the client’s cultural preferences may undermine autonomy and comfort. Respect for culturally meaningful foods is important in postpartum care.

D. "Does the doctor know that you are eating that?": This response implies unnecessary medical concern and can create anxiety or mistrust. Seaweed soup is generally safe postpartum, and there is no need to involve the physician for routine dietary choices.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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