The nurse prepares to administer blood to the patient. Which is the nurse's priority action?
a. Determining patient history of autologous blood donations
b. Assessing patient baseline vital signs be-fore the transfusion
c. Confirming the rate of the blood infusion with the healthcare provider
d. Identifying patient blood type, cross-match, and blood product
D
The most critical intervention to administer blood products safely is to accurately identify patient, blood type, cross-match, and blood product because an identification error potentially leads to devastating adverse effects, including hypersensitivity reactions, renal damage, and death. The nurse follows agency policy throughout the process of blood administration to prevent complica-tions from the administration of blood products. Assessing patient vital signs for baseline data is very important for comparison during the transfusion because the data provide the nurse with a basis of comparison to evaluate patient changes. The patient's history of blood donations is irre-levant information unless the donations left the patient grossly anemic. The nurse clarifies any orders when a question develops. Most agency policies do not routinely require confirmation of the infusion rate.
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During the visit to the pediatric office, a nurse observes the mother frequently looking at the infant and massaging the infant. From these observations, the nurse's conclusion should be:
1. Positive maternal–infant attachment. 2. Inadequate; more data are needed to assess the mother–infant relationship. 3. That the mother might be overwhelmed by the demands of infant care. 4. That the mother is trying to show the nurse that she can be affectionate to the infant.
Which statement by the pregnant client indicates that teaching has been effective?
1. "I should not have sex, because this is my first pregnancy." 2. "Some sexual positions should be avoided during pregnancy." 3. "We should quit having sex when I get to 8 months." 4. "I can tell my partner that having sex won't hurt the baby."
The nurse working in a pediatric burn unit explains to new registered nurses that which is the most common cause of death in burned children?
A. Hypovolemic shock B. Infection C. Sepsis D. Thrombotic events
When a nurse is caring for a client diagnosed with neurologic deficit who has begun responding to those around him, what therapy should the nurse suggest to help strengthen muscles that are under voluntary control?
A) Occupational therapy B) Range-of-motion (ROM) exercises C) Recreational therapy D) Physiotherapy