A nurse preparing to start a blood transfusion will use which type of tubing?
An air vent to let bubbles into the blood
One with a filter to ensure that clots do not enter the patient
An injection port to mix additional electrolytes into the blood
Two-way valves to allow the patient's blood to mix and warm the blood transfusing
The Correct Answer is B
A. An air vent allowing bubbles into the blood would be unsafe and can cause air embolism, so this option is incorrect.
B. Using tubing with a filter is standard practice for blood transfusions to prevent clots and debris from entering the patient’s bloodstream, making this the correct choice.
C. Mixing additional electrolytes into the blood is not a standard practice during transfusions, as it can cause complications; thus, this option is not appropriate.
D. Two-way valves are not typically used in blood transfusion setups; the goal is to keep the blood product separate from other fluids unless specifically indicated.
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Correct Answer is D
Explanation
A. The belief tool typically involves assessing specific beliefs but does not encompass the broader scope of spiritual well-being.
B. The FICA assessment tool focuses on Faith, Importance, Community, and Address, but it is not characterized by a lengthy questionnaire.
C. The Hope scale assesses a patient's sense of hope but does not specifically address spirituality in depth.
D. The spiritual well-being scale includes multiple questions that explore various aspects of spirituality, including the relationship with God and life purpose, making it the most appropriate choice for this assessment.
Correct Answer is A
Explanation
A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.