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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?

A.

Skin color

B.

Hemoglobin level

C.

Fluid intake

D.

Temperature

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

Rationale:

A. It is important for clients with borderline personality disorder to receive specialized follow-up care from a mental health provider to address their specific needs and manage their condition effectively.

B. Clients with borderline personality disorder often benefit from continued mental health care to ensure proper management of symptoms and prevent relapse.

C. While following up with a regular doctor is important, it is crucial for the client to see a mental health provider for ongoing treatment.

D. Assuming the client is well based on progress made in a short period does not address the need for continued mental health care.

Correct Answer is ["A","C","D"]

Explanation

Rationale:

A. Protein intake should be limited in clients with CKD to reduce the burden on the kidneys, as excessive protein can accelerate kidney damage.

B. Caloric intake typically needs to be adequate to meet energy requirements, not necessarily limited unless advised by a healthcare provider based on specific health needs.

C. Sodium intake should be restricted to prevent fluid retention and hypertension, which can worsen kidney function.

D. Phosphorous should be limited to avoid hyperphosphatemia, which can lead to bone and cardiovascular problems in CKD patients.

E. Calcium intake is usually maintained or adjusted carefully, rather than broadly limited, to manage bone health and prevent complications associated with CKD.

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