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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 D

Explanation

Rationale:

A. Clients with active tuberculosis should not be placed in a room with other clients, even if they require droplet precautions, as TB requires airborne precautions.

B. While PPE protocols are important, the most critical precaution for TB is ensuring the client is in the correct environment to prevent airborne transmission.

C. Wearing gowns, masks, and gloves is important, but the most essential measure is the room's ventilation system.

D. Active tuberculosis is an airborne infectious disease, so the client should be placed in a private room with a negative pressure ventilation system to prevent the spread of the bacteria through the air.

Correct Answer is C

Explanation

Rationale:

A. HIV infection can cause cognitive impairment, but it typically does not present with fluctuating cognition and visual hallucinations as primary symptoms.

B. Traumatic brain injury can lead to cognitive changes, but it is not typically associated with fluctuating cognition and visual hallucinations.

C. Lewy body disease is characterized by fluctuating cognition, visual hallucinations, and motor symptoms, making it the most likely diagnosis for these symptoms.

D. Prion disease is associated with rapidly progressive dementia but not specifically with fluctuating cognition and visual hallucinations.

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