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. Awareness of potential for self-harm is the priority as it directly impacts the safety and immediate well-being of the client with borderline personality disorder.
B. Medication compliance is important but secondary to immediate safety concerns.
C. Information about insurance coverage is relevant but does not address the immediate psychological safety needs.
D. Resources for group therapy are helpful but not as urgent as ensuring the family is aware of and can respond to self-harm risks.
Correct Answer is C
Explanation
Rationale:
A. A drug recovery support group can be beneficial for ongoing support but does not specifically address the work-related needs of a nurse returning to practice.
B. An early-release incarceration program is not relevant to the context of a nurse returning to work after completing treatment for substance abuse.
C. An Alternative-to-Discipline (ATD) program is designed to support healthcare professionals returning to work after treatment for substance use disorders. These programs focus on monitoring and supporting the nurse while ensuring public safety.
D. An involuntary long-term residential treatment is not applicable to a nurse who has already completed a treatment program and is preparing to return to work.