A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
Skin color
Hemoglobin level
Fluid intake
Temperature
The Correct Answer is B
Rationale:
A. While skin color may be an indicator of overall health, it is not the most crucial data point before administering packed RBCs.
B. The hemoglobin level is the most important data to assess before administering packed RBCs, as it provides direct information about the client’s need for the blood transfusion and helps evaluate the effectiveness of the intervention.
C. Fluid intake is important in overall client assessment but is not as immediately relevant as hemoglobin levels when preparing to administer packed RBCs.
D. Temperature should be monitored to check for any signs of infection, but it is not the primary concern when deciding to proceed with a blood transfusion.
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Correct Answer is D
Explanation
Rationale:
A. Action involves actively making changes or implementing strategies to alter behavior. The client's refusal to follow dietary advice indicates they are not actively engaging in behavior change.
B. Preparation entails planning and getting ready to make a change. The client’s statement shows no intention of preparing for a change.
C. Contemplation involves recognizing the need for change and considering it but not yet committed to making it. The client’s dismissive attitude suggests they are not at this stage.
D. Precontemplation is characterized by a lack of awareness or denial of the need for change. The client’s indifference to the dietary recommendations reflects this stage, as they are not yet considering changing their behavior.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Bananas are high in potassium and should be avoided by clients with chronic kidney disease.
B. Green beans are relatively low in potassium compared to other options and do not need to be avoided.
C. Tomatoes are high in potassium and should be limited in the diet.
D. Raisins are high in potassium and should be avoided.
E. Asparagus is not particularly high in potassium and can generally be included in a renal diet.