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 {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
- Lack of sleep: Decreased need for sleep is a core feature of mania, where individuals may go days with minimal rest and still appear energetic or overly active. It is not a defining feature of psychosis, though it may occur secondarily.
- Pressured speech: Pressured, rapid, and difficult-to-interrupt speech is strongly associated with mania, reflecting accelerated thought processes and elevated mood. It is uncommon in psychosis unless mania and psychotic features coexist.
- Disorganized thought process: This is a hallmark of psychosis, often seen in disorders like schizophrenia. It includes loose associations, tangentiality, and difficulty organizing ideas, and can impair communication significantly.
- Excessive spending habits: Engaging in impulsive or risky financial behaviors is a classic symptom of mania, often driven by grandiosity or impaired judgment. This behavior is not typical of psychosis unless mania is also present.
- Hallucinations: Perceptual disturbances such as seeing or hearing things that are not present are definitive features of psychosis. While they can occur in severe mania with psychotic features, they are primarily linked to psychotic disorders.
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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