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. Dental decay is a common result of frequent vomiting in bulimia nervosa due to exposure of teeth to stomach acid.
B. Bulimia nervosa often involves fluctuations in weight rather than a consistently lower weight, as it includes binge eating episodes.
C. Hypokalemia (low potassium) is more commonly associated with bulimia due to vomiting rather than hyperkalemia (high potassium).
D. Amenorrhea (absence of menstruation) may occur in bulimia nervosa but is less specific than dental decay for the condition.
Correct Answer is B
Explanation
Rationale:
A. Placing a client with active tuberculosis in a room with another client increases the risk of airborne transmission of the infection, which is inappropriate for infection control.
B. A room with air exhaust directly to the outdoor environment is ideal for a client with active tuberculosis because it provides negative pressure, helping to contain and prevent the spread of the infectious airborne particles.
C. The ICU is typically reserved for critically ill patients requiring intensive monitoring and care, and it may not provide the necessary infection control measures for TB.
D. A room near the nurses' station would not ensure the negative pressure ventilation needed to prevent airborne transmission of tuberculosis.