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 A
Explanation
Rationale:
A. Sore throat and muscle aches are common symptoms of agranulocytosis, a serious side effect of clozapine, indicating a potentially dangerous drop in white blood cells.
B. Severe restlessness is not a primary indicator of agranulocytosis but could be related to other side effects or symptoms.
C. Increased anxiety and suicidal ideations are not specific symptoms of agranulocytosis but can be related to psychiatric conditions or medication effects.
D. Respiratory depression and a comatose state are not typical signs of agranulocytosis and would indicate a more severe, different medical emergency.
Correct Answer is D
Explanation
Rationale:
A. An inverted P wave is not specifically associated with hypokalemia; it can be seen in various other conditions.
B. An elevated ST segment is not characteristic of hypokalemia; it is more associated with other conditions such as myocardial ischemia.
C. A wide QRS complex can occur with hypokalemia but is also seen in other conditions.
D. An abnormally prominent U wave is a classic sign of hypokalemia and can be seen in EKG changes associated with low potassium levels.