Author Question: After an assessment of a client, a nurse determines that the extremities are cool and pale. An ... (Read 72 times)

fagboi · **on:** Jul 24, 2018

After an assessment of a client, a nurse determines that the extremities are cool and pale. An appropriate nursing diagnosis is:

A. Impaired skin integrity
B. Altered tissue perfusion
C. Fluid volume deficit
D. Altered nutritional state

Question 2

The patient is to receive 1 unit of packed RBCs. The nurse obtains the blood from the blood bank and returns to the unit to find that the patient has been taken to radiology for a CT scan and is expected to return in about an hour.

What should the nurse do? a. Go to radiology and administer the blood.
b. Keep the blood refrigerated until the patient returns.
c. Return the blood to the blood bank.
d. Hang the blood in the patient's room and start it when the patient returns.

ttt030911 · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

B
B. Altered tissue perfusion would be associated with decreased circulation leading to cool and pale skin with capillary refill >2.5 seconds.
A. Impaired skin integrity would be associated with a breakdown in the skin surface.
C. Fluid volume deficit would be demonstrated with dry skin with tenting.
D. Altered nutritional state can refer to both more than body requirements or less than body requirements.

Answer to Question 2

C
Initiate the blood transfusion within 30 minutes of the time of release from the blood bank. If you cannot do this because the patient is in the bathroom or the physician has to be notified of an elevated temperature, immediately return the blood to the blood bank, and retrieve it when you can administer it.