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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Rationale:
A. The primary criterion for removing restraints is that the client must be calm and cooperative, indicating that the immediate safety concern has been addressed.
B. Verbalizing remorse is not a requirement for removing restraints; the focus is on the client's behavior and cooperation.
C. The provider does not need to be present for the nurse to assess the client's readiness for removal of restraints, although provider orders and assessments are important.
D. Simply verbalizing anger does not indicate that the restraints can be removed; the client must demonstrate appropriate behavior and cooperation.
Correct Answer is D
Explanation
Rationale:
A. A blood pressure of 102/66 mm Hg is within normal limits for a postoperative client.
B. Straw-colored urine is a normal finding for a postoperative client.
C. A respiratory rate of 18/min is within normal limits.
D. Yellow-green drainage from the surgical incision can indicate infection or other complications and should be reported to the provider for further evaluation.