A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion?

The client's lung sounds remain clear during the transfusion.

The client's blood pressure increases to 140/85 mm Hg following the transfusion

The client's hemoglobin level increases following the transfusion.

The client is afebrile during the transfusion.

Answer and Explanation

The Correct Answer is C

Rationale:

A. The client's lung sounds remain clear during the transfusion: Clear lung sounds indicate the absence of fluid overload or pulmonary complications, which is a safety indicator, but it does not reflect the effectiveness of the transfusion in improving oxygen-carrying capacity.

B. The client's blood pressure increases to 140/85 mm Hg following the transfusion: A sudden rise in blood pressure could indicate fluid overload or a transfusion reaction, not necessarily a positive response to the transfusion.

C. The client's hemoglobin level increases following the transfusion: An increase in hemoglobin indicates that the transfused red blood cells have effectively raised the client’s oxygen-carrying capacity, demonstrating a positive therapeutic response.

D. The client is afebrile during the transfusion: Remaining afebrile indicates the absence of a febrile transfusion reaction, which is a safety measure, but it does not show that the transfusion achieved its therapeutic goal.

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Correct Answer is A

Explanation

A. Urinary output 20 mL/hr: A urinary output less than 30 mL/hr in an adult indicates potential renal hypoperfusion or urinary retention. This is a priority finding that should be reported to the provider promptly.

B. Serous drainage on abdominal dressing: Serous drainage is a normal postoperative finding, indicating normal wound healing and fluid exudate. It does not require immediate provider notification.

C. Temperature 37.6° C (99.7° F): This temperature is slightly elevated but within the expected postoperative range due to the inflammatory response. It does not indicate an urgent complication.

D. Blood pressure 100/70 mm Hg: This blood pressure is within normal limits for many adults and is not necessarily concerning in a postoperative context unless accompanied by other symptoms such as tachycardia or dizziness.

A. Decreased respirations B. Polyuria C. Bradycardia D. Orthostatic hypotension

Correct Answer is D

Explanation

A. Decreased respirations: Moderate dehydration typically does not cause respiratory depression. Respiratory changes are more commonly associated with severe acid-base imbalances or advanced dehydration.

B. Polyuria: Dehydration leads to decreased fluid volume, which generally results in oliguria (reduced urine output) rather than polyuria. Increased urination is not an expected finding in moderate dehydration.

C. Bradycardia: Dehydration usually causes a compensatory increase in heart rate (tachycardia) to maintain cardiac output. Bradycardia is not typical unless there is a severe or underlying cardiac issue.

D. Orthostatic hypotension: Loss of fluid volume from diarrhea and vomiting can decrease circulating blood volume, leading to a drop in blood pressure upon standing. This is an expected cardiovascular manifestation of moderate dehydration in school-age children.

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A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion?

Nursing Test Bank

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