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 D

Explanation

Ask the partner to list specific concerns.

A. Evaluate the changes the partner requests: This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
B. Review the client's plan of care: This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
C. Analyze other reports of poor care to look for trends: This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
D. Ask the partner to list specific concerns: This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.

A. "I'll use isopropyl alcohol to clean my hearing aids.” B. "I'll replace the batteries every 2 weeks.” C. "I'll clean my ear with cotton swabs before I insert my hearing aids.” D. "I'll disconnect the battery when I remove my hearing aids.”

Correct Answer is D

Explanation

Choice A rationale:

Using isopropyl alcohol to clean hearing aids is not recommended. Isopropyl alcohol can damage the hearing aid components, especially the plastic parts. It is essential to use cleaning solutions specifically designed for hearing aids to avoid damaging them. Including this statement indicates a misunderstanding of proper hearing aid care.

Choice B rationale:

Replacing the batteries every 2 weeks is a standard recommendation for hearing aid users. Hearing aid batteries typically last 1 to 2 weeks, depending on usage. Regular battery replacement ensures the hearing aids continue to function optimally. This statement demonstrates an understanding of the basic care required for behind-the-ear hearing aids.

Choice C rationale:

Cleaning the ear with cotton swabs before inserting hearing aids is not advisable. Cotton swabs can push earwax further into the ear canal, leading to impaction. Excessive earwax can interfere with hearing aid function. Instead, clients should be encouraged to clean the outer parts of the hearing aids and avoid inserting any objects, including cotton swabs, into the ear canal.

Choice D rationale:

Disconnecting the battery when removing hearing aids is the correct practice. By disconnecting the battery, the client ensures that the hearing aids are turned off, preserving battery life and preventing unnecessary drainage. This statement indicates an understanding of proper hearing aid care and demonstrates the client's ability to maintain the device effectively.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

Correct Answer is D

Explanation

A nurse is teaching a client how to care for his behind-the-ear hearing aids.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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