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 B
Explanation
A. Notify the blood bank of the discrepancy:
This choice suggests that there is a discrepancy between the blood type of the unit on hand (type B) and the client's blood type (type AB). However, in reality, there is no discrepancy in this case because individuals with type AB blood are universal recipients and can receive blood from donors of any blood type, including type B. Therefore, there is no need to notify the blood bank of any discrepancy.
B. Administer the blood as ordered:
This choice is the correct action. Type AB individuals are known as universal recipients because they can safely receive blood from donors of any blood type (A, B, AB, or O) without causing a major transfusion reaction. Since the client has type AB blood and the unit of blood on hand is type B, the nurse can administer the blood as ordered without concerns about blood type compatibility.
C. Complete an incident report:
Completing an incident report is typically done when an unexpected event or error occurs during patient care. In this scenario, there is no error or unexpected event related to blood type compatibility, so there is no need to complete an incident report.
D. Contact the provider for further orders:
Contacting the provider for further orders would be necessary if there were a specific reason or concern related to the blood transfusion that requires clarification or additional instructions. However, in this case, there are no issues with blood type compatibility, so contacting the provider is not necessary.
Correct Answer is C
Explanation
A. Whether the client and involved family members understand dietary changes and the role of nutrition:
This assessment is important as diet plays a crucial role in managing coronary artery disease (CAD) and preventing further complications. Understanding dietary changes, such as reducing saturated fats, sodium intake, and incorporating heart-healthy foods like fruits, vegetables, and whole grains, is essential. Nutrition education can help clients and their families make informed choices that promote heart health and improve overall well-being. However, while understanding dietary changes is significant, it may not be the most critical determination during the initial intake assessment, especially when compared to immediate concerns like recognizing acute cardiac symptoms.
B. Whether the client and involved family members understand the role of genetics in the etiology of the disease:
Understanding the genetic factors contributing to coronary artery disease can provide valuable insights into the client's risk factors and potential hereditary predispositions. This knowledge can help guide screening, prevention, and management strategies tailored to the client's specific genetic profile. While genetic factors are important considerations in CAD, they typically require a more detailed evaluation and may not be the primary focus during the initial intake assessment, especially compared to immediate concerns related to symptom recognition and response.
C. Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately:
This is a crucial assessment because recognizing symptoms such as chest pain, shortness of breath, nausea, sweating, and arm or jaw pain is essential in identifying a potential heart attack or unstable angina. Knowing when to seek emergency medical assistance and how to respond appropriately can significantly impact outcomes and reduce the risk of complications. Immediate response to acute cardiac symptoms is a critical aspect of CAD management, making it a top priority during the intake assessment.
D. Whether the client and involved family members understand the importance of social support and community agencies:
Social support and community resources play a valuable role in CAD management, providing emotional support, access to education programs, rehabilitation services, and other supportive resources. Understanding the importance of social support and knowing how to access community agencies can enhance the client's overall well-being and facilitate long-term management.
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