A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take?
Contact the provider for further orders.
Notify the blood bank of the discrepancy.
Administer the blood as ordered.
Complete an incident report.
The Correct Answer is C
Choice A: Contacting the provider for further orders is not necessary, because the client has type AB blood, which is compatible with any other blood type. The client can receive type B blood without any adverse reactions.
Choice B: Notifying the blood bank of the discrepancy is not required, because there is no discrepancy. The blood bank sent the correct type of blood for the client, according to their blood type.
Choice C: Administering the blood as ordered is the correct action, because type B blood is compatible with type AB blood. The client will not have any transfusion reactions or complications from receiving this type of blood.
Choice D: Completing an incident report is not appropriate, because there is no incident. The nurse did not make any error or mistake in administering the blood to the client. There is no need to document or report anything unusual.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: To calculate the total body surface area (TBSA) affected by burns using the Rule of Nines, the body is divided into sections, each representing a percentage of TBSA:
- Front of one leg = 9%
- Back of one leg = 9%
- Front of one arm = 4.5%
- Back of one arm = 4.5%
Now for the calculation:
-
Both legs (front and back):
- Front of both legs = 9% × 2 = 18%
- Back of both legs = 9% × 2 = 18%
- Total for both legs = 18% + 18% = 36%
-
Both arms (front and back):
- Front of both arms = 4.5% × 2 = 9%
- Back of both arms = 4.5% × 2 = 9%
- Total for both arms = 9% + 9% = 18%
-
Total TBSA:
- Legs (36%) + Arms (18%) = 54%
The nurse should document burns to 54% of the client's total body surface area (TBSA).
Choice B Reason:This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.
Choice C Reason: This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.
Choice D Reason: This choice is incorrect because it uses a random percentage that does not correspond to any rule or calculation.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because monitoring the client's electrolyte levels is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice B Reason: This is correct because suctioning saliva from the client's mouth is the highest priority, as it prevents airway obstruction and aspiration, which can lead to respiratory distress and infection.
Choice C Reason: This is incorrect because recording the client's intake and output is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice D Reason: This is incorrect because performing passive range of motion on each extremity is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
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