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
Explanation
Rationale:
A. Stage 2 (moderate) of alcohol withdrawal involves symptoms such as increased blood pressure and heart rate, mild confusion, and tremors, but does not typically include hallucinations or severe agitation.
B. Stage 3 (severe) alcohol withdrawal includes severe symptoms such as hallucinations (e.g., seeing spiders), severe agitation, and possible delirium tremens, which are consistent with the client's manifestations.
C. Stage 1 (mild) symptoms generally include mild anxiety and tremors but do not include hallucinations or significant changes in mental status.
D. The client’s manifestations indicate severe withdrawal symptoms, not just a general description.
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.