A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

Hemoglobin 14.9 g/dL

WBC count 12.000/mm

Potassium 48 mEq

BUN 18 mg/dL

Answer and Explanation

The Correct Answer is A

A. Correct. A hemoglobin level of 14.9 g/dL indicates that the client has an adequate amount of oxygen-carrying capacity in the blood, which is the goal of blood transfusion therapy.
B. Incorrect. A WBC count of 12,000/mm3 is slightly elevated and may indicate an infection or inflammation, which are not related to blood transfusion therapy.
C. Incorrect. A potassium level of 48 mEq/L is dangerously high and may cause cardiac arrhythmias, muscle weakness, or paralysis. This is not an expected outcome of blood transfusion therapy and may indicate hemolysis or renal impairment.
D. Incorrect. A BUN level of 18 mg/dL is within the normal range and does not reflect the effectiveness of blood transfusion therapy.

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Correct Answer is C

Explanation

Choice A rationale:

Instructing the client to maintain a full bladder is not relevant to an amniocentesis procedure. A full bladder may be necessary for certain other procedures, such as a pelvic ultrasound, but not for amniocentesis.

Choice B rationale:

Administering a tocolytic 30 minutes before the procedure is not a standard practice for amniocentesis. Tocolytics are medications used to suppress uterine contractions and are not routinely administered before this procedure.

Choice C rationale:

Monitoring the fetal heart rate throughout the procedure is essential during an amniocentesis. This helps assess the well-being of the fetus and ensures that the procedure is not causing fetal distress. Any changes in fetal heart rate can indicate potential complications and may require immediate intervention.

Choice D rationale:

Placing the client in Trendelenburg position during the procedure is not recommended for amniocentesis. Trendelenburg position, where the body is supine with the legs elevated higher than the head, is not routinely used during this procedure and may cause discomfort to the client without providing significant clinical benefits.

A. The client is taking numerous deep, measured breaths B. The client is calmly telling their partner that "the staff here is so controlling C. The client is sitting with their head in their hands and appears to be crying D. The client is pacing around the chair in which their partner is sitting

Correct Answer is D

Explanation

The client is pacing around the chair in which their partner is sitting.

Rationale:

A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.

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A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client prior to an amniocentesis.Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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