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 ["B","C","E"]
Explanation
Rationale:
A. Nylon socks are generally not considered a risk for self-harm and can be safely kept with the client.
B. A glass-framed picture presents a risk as the glass could be broken and used for self-harm. This item should be taken home.
C. Lace-up tennis shoes have long laces that could be used for self-harm, making them unsafe for a client at risk of suicide.
D. Cotton underwear does not pose a significant risk for self-harm and can be kept with the client.
E. A necklace could be used for self-harm, such as strangulation, and should be taken home to ensure the client's safety.
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Living in a homeless shelter is a significant social determinant that can impact mental health due to instability, lack of privacy, and increased stressors.
B. Access to a grocery store is important because food insecurity and lack of access to nutritious food can negatively affect mental and physical health.
C. Being employed part-time at minimum wage can contribute to financial stress, impacting mental health due to economic instability and potential lack of access to healthcare.
D. While a history of diabetes mellitus is relevant to overall health, it is not a direct social determinant of mental health.
E. Owning a small dog may have a positive impact on mental health due to companionship but is not a primary social determinant in this context.