Ati lpn med surg haematology
Ati lpn med surg haematology ( 32 Questions)
A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?
Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.
Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.
Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.
Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.
A. Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.
B. Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.
C. Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.
D. Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.