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 C

Explanation

Rationale:

A. Administer ondansetron to the client for nausea: Treating nausea is important for comfort, but it does not address the most urgent risk. Nausea is not immediately life-threatening compared with potential complications from medication overdose.

B. Obtain a blood glucose level: Checking blood glucose can provide useful information, but there is no indication of hypoglycemia or diabetes-related crisis in this scenario. It is not the priority action.

C. Implement seizure precautions for the client: The client has been doubling the bupropion dose, which significantly increases the risk of seizures, especially at doses above the prescribed maximum. Seizure precautions address an immediate life-threatening risk and should be the first intervention.

D. Obtain the client's weight: Monitoring weight is important for assessing nutritional status and the severity of depression, but it is not an immediate safety concern. Life-threatening risks, such as seizures, take priority.

A. Activity level B. White blood cell count C. Sodium level D. Potassium level E. Hallucinations

Correct Answer is ["A","C","E"]

Explanation

A. Activity level: Restlessness, pacing, and inability to remain seated are early neurological manifestations of water intoxication, stemming from cerebral edema related to hyponatremia. These signs often precede more severe symptoms like seizures.

B. White blood cell count: A count of 9,100/mm³ is within normal limits and does not indicate water intoxication. This value is unrelated to the dilutional effects of excessive fluid intake.

C. Sodium level: A sodium of 130 mEq/L indicates hyponatremia, which is a hallmark laboratory finding in water intoxication due to dilutional effects from excess fluid intake. Low sodium can cause neurological changes and altered mental status.

D. Potassium level: A potassium of 3.6 mEq/L is within the normal range and does not support a diagnosis of water intoxication. Potassium is less affected by acute overhydration compared to sodium.

E. Hallucinations: Responding to unseen stimuli can occur when hyponatremia causes cerebral swelling, disrupting normal brain function. In clients with psychotic disorders, excess water intake can exacerbate hallucinations or make them more pronounced.

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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

Naxlex Comprehensive Predictor Exams

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