A nurse is reviewing a client's laboratory results before administering a blood transfusion.
Which of the following results should the nurse report to the provider before proceeding with the transfusion?
Hemoglobin 8 g/dL
Platelets 150,000/mm3
Potassium 5.5 mEq/L
Blood type AB positive
The Correct Answer is C
Potassium 5.5 mEq/L
Rationale: The nurse should report the potassium level of 5.5 mEq/L to the provider before proceeding with
the blood transfusion, as this indicates hyperkalemia, which can cause cardiac arrhythmias or arrest. Blood transfusion can increase potassium levels further, especially if the blood has been stored for a long time or if it is administered rapidly.
Incorrect options:
A) Hemoglobin 8 g/dL - This is a low hemoglobin level, which indicates anemia, but it is not a contraindication for blood transfusion. In fact, blood transfusion may be indicated to treat severe anemia and improve oxygen delivery to the tissues.
B) Platelets 150,000/mm3 - This is a normal platelet count, which indicates adequate clotting function. It is not a reason to withhold or delay blood transfusion.
D) Blood type AB positive - This is the client's blood type, which is compatible with any blood type for transfusion, as AB positive is the universal recipient. It is not a reason to report to the provider or stop the transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Check the tubing for any leaks or kinks.
Rationale: The nurse should check the tubing for any leaks or kinks, as continuous bubbling in the water seal chamber indicates an air leak in the system, which can impair lung re-expansion and drainage. The nurse should locate and seal the leak, and notify the provider if necessary.
Incorrect options:
A) Clamp the chest tube near the insertion site. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and other structures. The nurse should only clamp the chest tube briefly when changing the drainage system or assessing for an air leak.
C) Increase the suction pressure to the drainage system. - This is an incorrect action, as increasing the suction pressure to the drainage system can cause damage to the lung tissue and increase the risk of infection. The nurse should follow
the provider's prescription and the manufacturer's guidelines for setting and adjusting the suction pressure.
D) Document the finding as an expected outcome. - This is an incorrect action, as documenting the finding as an expected outcome implies that continuous bubbling in the water seal chamber is normal, which it is not. The nurse should document
the finding as an abnormal finding and report it to the provider.
Correct Answer is A
Explanation
Include the date and time of the assessment.
Rationale: The nurse should include the date and time of the wound assessment in the documentation, as this provides a chronological and accurate record of the client's condition and response to treatment.
Incorrect options:
B) Use abbreviations that are approved by the facility. - This is a partially correct statement, as the nurse should use abbreviations that are approved by the facility to ensure clarity and consistency in the documentation. However, this is not the best answer, as some abbreviations may still be confusing or ambiguous, and should be avoided or spelled out.
C) Copy and paste the previous assessment as a template. - This is an incorrect statement, as copying and pasting the previous assessment as a template can result in errors, omissions, or duplication of information, compromising the quality and integrity of the documentation.
D) Delete any inaccurate entries made by other staff members. - This is an incorrect statement, as deleting any entries made by other staff members is unethical and illegal, as it alters the original record and may affect the client's care or legal outcomes. The nurse should follow the facility's policy on correcting errors in documentation, which usually involves drawing a single line through the error, writing "error" above it, and signing and dating it.
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