H19-374_V1.0 Exam Questions and Answers

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A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will "beat out of her chest." The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
A. Starting an 18-gauge IV infusion
B. Administering the correct blood product to the correctclient
C. Having the consent form on the chart
D. Transfusing the blood in a 2-hour time frame
Answer: B
(A) An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. (B) The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. (C) Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. (D) The blood administration should take place over the ordered time frame designated by the physician.

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