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.

Answer and Explanation

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.

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Correct Answer is ["1712.32"]

Explanation

To calculate the client's total intake for the 8-hour shift, we need to convert all the volumes to milliliters (mL) and then add them together. Here are the given volumes and their conversions:

1,000 mL 0.9% sodium chloride IV (no conversion needed)

One 6-oz cup of coffee:

6 oz * 29.5735 (conversion factor for oz to mL) = approximately 177.44 mL

6 oz of water:

6 oz * 29.5735 = approximately 177.44 mL

One 180-mL bowl of soup (no conversion needed)

3 oz of flavored gelatin:

3 oz * 29.5735 = approximately 88.72 mL

3 oz of ice cream:

3 oz * 29.5735 = approximately 88.72 mL

Now, let's add up all the volumes:

1,000 mL (IV fluid) + 177.44 mL (coffee) + 177.44 mL (water) + 180 mL (soup) + 88.72 mL (gelatin) + 88.72 mL (ice cream) = 1,712.32 mL

Therefore, the nurse should document the client's total intake for the shift as approximately 1,712.32 mL.

A. Relieve client symptoms B. Extend survival C. Improve functional status D. Prevent endocarditis E. Limit physical activity

Correct Answer is ["A","B","C"]

Explanation

A. Relieve client symptoms - Heart failure can cause symptoms like shortness of breath, fatigue, swelling (edema), and difficulty exercising. Relieving these symptoms is an important goal to improve the client's quality of life and overall well-being.

B. Extend survival - Heart failure is a chronic condition that can significantly impact life expectancy. One of the goals of care is to optimize management to extend the client's survival and reduce the risk of complications.

C. Improve functional status - Heart failure can limit a person's ability to perform daily activities and exercise. Improving functional status involves strategies such as medication management, lifestyle modifications, and cardiac rehabilitation to enhance the client's ability to engage in daily activities and maintain independence.

D. Prevent endocarditis - Endocarditis is an infection of the inner lining of the heart chambers and heart valves. While preventing infections is important for overall health, preventing endocarditis may not be directly related to the primary goals of heart failure management. However, maintaining good hygiene and avoiding infections can contribute to the overall well-being of the client.

E. Limit physical activity - This statement is incorrect in the context of heart failure management. Encouraging appropriate levels of physical activity is often part of heart failure care. Physical activity, when tailored to the individual's abilities and guided by healthcare professionals, can improve cardiovascular function, strengthen muscles, and enhance overall health outcomes in clients with heart failure.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1712.32"]

Explanation

The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client's care? (Select All that Apply.)

Correct Answer is ["A","B","C"]

Explanation

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