The nurse admits a client in hypovolemic shock, and receives the ...

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The nurse admits a client in hypovolemic shock, and receives the following orders from the physician:  Initiate two large-bore IV lines.  Obtain STAT CBC with differential.  Type and cross for two units of whole blood.
 
   Insert an indwelling catheter to monitor output. What order would the nurse perform first? 1. Initiate IV lines.
  2. Complete requisitions for CBC.
  3. Complete requisitions for blood.
  4. Insert the indwelling catheter.

Question 2

The nurse is reviewing the potential complications of a transfusion with a client. Infections that may be long term in nature include:(Select all that apply) Standard Text: Select all that apply.
 
  1. Hepatitis B
  2. Graft-versus-host disease
  3. Hyperkalemia
  4. Sepsis
  5. HIV

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Answer to Question 1

1
Rationale: The priority nursing action is to initiate IV lines because the client might require blood or medications to be administered in order to compensate for the fluid volume deficit. The nurse may have someone else requisition the blood and laboratory work while the nurse initiates the IV lines. An indwelling catheter would be a lower-priority intervention.

Answer to Question 2

1,5
Rationale: Hepatitis B is a viral infection that is spread by blood and serum, and may be life-long in nature

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