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?
Match the client's blood type with the type and cross match specimen.
Confirm the provider's prescription matches the number on the blood component.
Ask the client to state his blood type and the date of the blood donation.
Ensure that the client's identification band matches the number on the blood unit.
The Correct Answer is D
A. Match the client's blood type with the type and cross match specimen. While type and crossmatch are important for allogeneic transfusions, an autologous transfusion uses the client’s own previously donated blood, so this is not the primary method for identification.
B. Confirm the provider's prescription matches the number on the blood component. Although important, this step alone does not verify the client’s identity. The nurse must also confirm the blood unit matches the correct client.
C. Ask the client to state his blood type and the date of the blood donation. Client recall is not a reliable form of identification for transfusion safety, as it is prone to error or misunderstanding.
D. Ensure that the client's identification band matches the number on the blood unit. This is the correct and safest method to confirm identity before administering an autologous blood product. It ensures the blood product is matched to the correct patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Contraction intensity increased by ambulation. This finding is typical of true labor, as walking or changing positions usually causes contractions to increase in strength, duration, and frequency. In contrast, false labor contractions often subside with rest or activity changes and do not intensify with movement.
B. Slow change in dilation and effacement. Any change in cervical dilation or effacement, even if slow, is more consistent with true labor. False labor does not produce any significant cervical change, and the cervix remains closed or minimally altered with time or contractions.
C. Presence of bloody show. Bloody show is the expulsion of the mucus plug mixed with blood, a common sign of cervical softening and dilation. This is a key indicator of true labor, as it reflects actual physical changes in preparation for delivery.
D. Intermittent painless contractions. These contractions, also called Braxton Hicks contractions, are a hallmark of false labor. They are usually irregular, mild, and do not lead to cervical changes. They often resolve with hydration, rest, or position changes and are considered a normal part of the body's preparation for labor, not the onset of true labor.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B,C"}}
Explanation
- Urticaria: Urticaria (hives) is a hallmark sign of an allergic reaction, particularly latex allergy, and typically appears quickly following exposure to allergens. It is not seen in malignant hyperthermia or hypovolemic shock.
- Wheezing: Wheezing can occur in latex allergy due to bronchospasm or airway edema. While respiratory compromise may happen in malignant hyperthermia, it is typically due to muscle breakdown and CO2 retention, not bronchospasm. Wheezing is not expected in hypovolemic shock.
- Muscle rigidity: Generalized rigidity, especially of the jaw (masseter spasm), is a key early sign of malignant hyperthermia, a life-threatening reaction to certain anesthetics. It is not a symptom of latex allergy or hypovolemic shock.
- Hypercapnia: An elevated PaCO₂ is an early, sensitive marker of malignant hyperthermia, resulting from increased CO₂ production due to sustained muscle contraction. This does not occur in latex allergy or hypovolemic shock.
- Tachycardia: Elevated heart rate can be seen in all three conditions: in malignant hyperthermia due to increased metabolic demand, in latex allergy due to anaphylactic reaction, and in hypovolemic shock as a compensatory response to fluid loss.
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