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 B

Explanation

Rationale:

A. Dietitian: A dietitian focuses on nutritional needs, which may be beneficial if the client has dietary concerns, but this does not directly address mobility issues related to lower extremity weakness.

B. Physical therapy: Physical therapists specialize in improving strength, balance, and mobility. A referral will help the client develop exercises and strategies to enhance function and reduce fall risk.

C. Case manager: A case manager coordinates healthcare services, but they do not directly provide rehabilitation for weakness. They may be involved later to arrange additional resources after therapy needs are determined.

D. Social services: Social services assist with psychosocial needs, financial support, and community resources, but they are not the primary referral for addressing physical mobility limitations.

A. Ensure that each client has a living will on file prior to treatment. B. Place copies of incident reports in clients' medical records. C. Obtain personal professional liability insurance coverage. D. Overestimate clients' acuity to prevent short staffing.

Correct Answer is C

Explanation

Rationale:

A. Ensure that each client has a living will on file prior to treatment: While advance directives are encouraged, clients have the right to choose whether to have one, and care cannot be delayed or denied if they do not.

B. Place copies of incident reports in clients' medical records: Incident reports are internal risk management tools and should not be placed in the medical record, as this could increase legal liability and compromise confidentiality.

C. Obtain personal professional liability insurance coverage: Having individual liability coverage provides additional protection beyond employer coverage, ensuring legal and financial support if malpractice claims arise.

D. Overestimate clients' acuity to prevent short staffing: Falsifying acuity levels is unethical and can result in disciplinary action or loss of license; staffing concerns should be addressed through proper administrative channels.

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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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