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 C
Explanation
Rationale:
A. Denial involves refusing to accept reality but is not as characteristic of borderline personality disorder as splitting.
B. Reaction formation involves behaving in a manner opposite to one's true feelings, which is not the primary defense mechanism in borderline personality disorder.
C. Splitting is a common defense mechanism in borderline personality disorder where the client views people or situations as all good or all bad, potentially causing conflict within the healthcare team.
D. Regression involves reverting to earlier developmental stages but does not typically cause division among healthcare providers.
Correct Answer is ["A","B","C","E"]
Explanation
Rationale:
A. Taking a lunch break is an important self-care practice to rest and recharge during a workday.
B. Eating balanced and nutritious meals is crucial for maintaining physical health and energy levels.
C. Establishing healthy boundaries helps prevent burnout and maintain work-life balance.
D. Regular exercise is recommended for overall well-being, but “occasionally” might not be sufficient for effective self-care.
E. Taking time for relaxation helps manage stress and maintain mental health.