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 C
Explanation
A. "Dehydration Is the primary reason for the pain that is experienced during a sickle cell crisis; try to increase your son's fluid intake."
This response is not the best choice because while dehydration can indeed exacerbate sickle cell crises and lead to complications, it is not the primary reason for the pain experienced during a sickle cell crisis. The severe pain during a crisis is primarily due to vaso-occlusion, where sickled red blood cells block blood flow in the small blood vessels, leading to tissue ischemia and pain. While adequate hydration is important in managing sickle cell disease, it alone does not address the underlying cause of the pain during a crisis.
B. "We really don't know what causes the pain that is experienced during a sickle cell crisis."
This response is not accurate and not the best choice because the medical community does understand the underlying cause of pain during a sickle cell crisis. It is primarily due to vaso-occlusion, as mentioned earlier, where sickled red blood cells block blood flow in the blood vessels.
C. "Sickled cells get clogged in the blood vessels, preventing blood from getting to the tissues, which causes the severe pain of a crisis."
This response is the best choice because it provides an accurate and clear explanation of why individuals with sickle cell anemia experience severe pain during a sickle cell crisis. It addresses the underlying mechanism of vaso-occlusion, where sickled red blood cells block blood flow in the small blood vessels, leading to tissue ischemia and severe pain.
D. "You will need to discuss this with your doctor. I cannot explain why this pain occurs to your
son."
This response is not the best choice because the nurse should be able to provide basic information about the disease and its symptoms to the mother. It's important for healthcare professionals to educate patients and their families about their condition to improve understanding and facilitate better management and coping strategies.
Correct Answer is D
Explanation
A. Increasing fluids to maintain BP: While staying well-hydrated is generally beneficial for overall health and blood pressure management, increasing fluids is not the primary intervention for dizziness associated with alpha-adrenergic blockers. Alpha-blockers can cause orthostatic hypotension, which may lead to dizziness upon standing, especially if rising quickly.
B. Taking medication first thing in the morning: Taking medication in the morning is a common recommendation for many medications, including some antihypertensive drugs. However, for alpha-adrenergic blockers that can cause orthostatic hypotension, timing of medication administration is not the primary concern in addressing dizziness.
C. Stopping medication if dizziness persists: Abruptly stopping medication without consulting a healthcare provider is not recommended, especially for antihypertensive medications. It's important for clients to follow their prescribed treatment plan and communicate any side effects or concerns to their healthcare provider for appropriate management.
D. Rising slowly from a lying or sitting position: This is the correct emphasis for the nurse. Alpha-adrenergic blockers can cause orthostatic hypotension, a drop in blood pressure upon standing, which can lead to dizziness or lightheadedness. To minimize this risk, the client should be advised to rise slowly from lying down or sitting to standing positions. This gradual movement helps the body adjust to changes in blood pressure more effectively.
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