A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take to identify the client? (Select All that Apply.)
Confirm that the room number matches the medical record.
Compare the client identification number to the blood component tag number.
Verify the provider's prescription with another RN.
Ask the client to verbalize if the blood type is Rh-negative or positive.
Scan the barcode on the client's identification band.
Correct Answer : B,E
A. Confirm that the room number matches the medical record. Room numbers should never be used as a sole method to identify a client. Room assignments can change, and relying on them could lead to errors.
B. Compare the client identification number to the blood component tag number. Matching the client identification number to the blood component tag ensures the blood is being administered to the correct client. This is a key step in preventing transfusion errors.
C. Verify the provider's prescription with another RN. While this is an important step in the blood administration process, it is not specifically related to identifying the client.
D. Ask the client to verbalize if the blood type is Rh-negative or positive. Clients may not know their blood type, and relying on their verbal confirmation is unsafe. The blood type must be confirmed through laboratory testing and matched with the blood being administered.
E. Scan the barcode on the client's identification band. Scanning the barcode on the client’s identification band is a reliable and commonly used method for verifying the client’s identity in modern healthcare settings. This ensures that the blood is administered to the correct client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Take the iron with dairy products to enhance absorption: This statement is incorrect. Calcium-rich foods, such as dairy products, can inhibit iron absorption. It's recommended to take iron supplements with vitamin C-rich foods or beverages to enhance iron absorption.
B. Limit foods high in fiber due to the risk for diarrhea: While some individuals may experience gastrointestinal side effects such as constipation or diarrhea when taking iron supplements, it is not generally recommended to limit foods high in fiber. Adequate fiber intake is important for overall digestive health.
C. Increase the intake of vitamin E to enhance absorption: Vitamin E does not directly enhance iron absorption. Vitamin C is the nutrient that enhances iron absorption, so increasing intake of vitamin C-rich foods or taking vitamin C supplements along with iron supplements can improve iron absorption.
D. Iron will cause the stools to darken in color: This statement is correct. Iron supplements can cause stools to become dark or even black in color. This is a harmless side effect known as "iron stools" and is caused by the reaction of iron with substances in the digestive tract.
Correct Answer is D
Explanation
A. Pleurisy:
Pleurisy is inflammation of the pleura, which is the lining surrounding the lungs. It can cause sharp chest pain that worsens with breathing. While pleurisy can be associated with conditions such as infections, pneumonia, or pulmonary embolism, it is not typically directly diagnosed or investigated using the brain (B-type) natriuretic peptide (BNP) test. The symptoms of pleurisy may include chest pain, especially with deep breathing, coughing, or sneezing.
B. Cardiomyopathy:
Cardiomyopathy refers to diseases of the heart muscle, which can lead to impaired heart function. Cardiomyopathy can cause symptoms such as fatigue, shortness of breath, chest pain, and fluid retention. While elevated BNP levels can be observed in some cases of cardiomyopathy, the BNP test is not specific to cardiomyopathy alone. It is often used to assess and diagnose heart failure, a condition that can result from various cardiac abnormalities, including cardiomyopathy.
C. Valve Dysfunction:
Valve dysfunction refers to abnormalities or malfunctions of the heart valves, such as stenosis (narrowing) or regurgitation (leakage). Valve dysfunction can lead to symptoms such as shortness of breath, chest pain, palpitations, and fatigue. While valve dysfunction can contribute to heart failure by causing pressure and volume overload on the heart chambers, the BNP test is primarily used to assess heart failure itself rather than specifically identifying valve dysfunction.
D. Heart Failure:
Heart failure is a condition in which the heart is unable to pump blood effectively to meet the body's needs. It can cause symptoms such as fatigue, shortness of breath, fluid retention (edema), and exercise intolerance. Elevated BNP levels are commonly observed in patients with heart failure, especially in cases of acute exacerbations or decompensated heart failure. The BNP test is used to assess and diagnose heart failure, as higher BNP levels indicate increased cardiac stress and volume overload.
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