The nurse prepares to administer blood to the client. Which is the nurse's priority intervention?
1. Determining client history of autologous blood donations
2. Assessing client baseline vital signs before the transfusion
3. Confirming the rate of the blood infusion with the provider
4. Identifying client blood type, cross-match, and blood product
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4. The most critical intervention to administer blood products safely is accurate iden-tification of client, blood type, cross-match, and blood product because an identifica-tion 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 complications from the administration of blood products.
2. Assessing client vital signs for baseline data is very important for comparison dur-ing the transfusion because the data provide the nurse with a basis of comparison to evaluate client changes.
1. Client history of blood donations is irrelevant information unless the donations left the client grossly anemic.
3. The nurse clarifies any prescription when a question develops; however, most agency policies do not routinely require confirmation of the infusion rate.
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A 20-month-old child is experiencing diarrhea. When planning the child's care, the nurse should prioritize assessments related to what health problem?
A) Electrolyte deficiencies B) Anorectal bleeding C) Anal fissures D) Nausea
A 16-year-old female presents at the emergency department complaining of right lower quadrant pain. She is diagnosed with appendicitis. When assessing this patient, what signs or symptoms should the nurse expect to find?
A) Rigid abdomen, Levine's sign, pain relief leaning forward B) Rebound tenderness, McBurney's sign, low-grade fever C) Right lower quadrant pain, Chvostek's sign, muscle guarding D) Periumbilical pain, Trousseau's sign, pain relief with pressure
The nurse is providing a client with education about major minerals. Which minerals should the nurse include in the teaching session? (Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Calcium 2. Iron 3. Fluoride 4. Chloride 5. Potassium
A client will be having a second-trimester abortion using misoprostol (Cytotec) and methotrexate. Which statement by the client indicates an understanding of the side effects to be expected with these medications?
1. "I might experience chest pain with these medications." 2. "I know that these medications will most likely cause bleeding when I urinate." 3. "These medications will cause tingling and weakness in my legs." 4. "I will probably run a fever for a few hours after I take these medications."