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. Cognitive Behavioral Therapy (CBT) is designed to help individuals manage grief by addressing and altering maladaptive thought patterns and behaviors related to their loss. This approach helps clients adapt to living with the loss and cope with their emotions.
B. Making funeral and burial arrangements is not within the scope of CBT; it focuses on managing emotional and cognitive responses to grief.
C. CBT does not focus on understanding specific events or details of a partner’s medical treatment but rather on the emotional and cognitive processing of grief.
D. CBT does not aim to answer questions about the reasons for a partner’s death but rather helps individuals cope with the emotional impact of the loss.
Correct Answer is A
Explanation
Rationale:
A. Stopping the transfusion is the priority action as it is essential to prevent further potential adverse effects and initiate an investigation of a possible transfusion reaction.
B. Assessing the skin for a rash is important but secondary to stopping the transfusion.
C. Notifying the provider is necessary, but the immediate priority is to stop the transfusion.
D. Covering the client with a blanket does not address the potential severity of a transfusion reaction.