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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Increased creatinine: Chronic kidney disease reduces the kidneys’ ability to filter waste products effectively, causing creatinine to accumulate in the blood. Elevated creatinine is a key indicator of declining renal function and is expected in this condition.
B. Increased calcium: Clients with chronic kidney disease often have decreased calcium levels due to impaired vitamin D activation and phosphate retention. Increased calcium would be unusual unless the client is receiving supplementation.
C. Increased bicarbonate: Metabolic acidosis is common in chronic kidney disease because the kidneys cannot adequately excrete hydrogen ions or reabsorb bicarbonate. This typically results in decreased, not increased, bicarbonate levels in the blood.
D. Increased hemoglobin: Anemia frequently occurs in chronic kidney disease due to reduced erythropoietin production by the kidneys. This leads to lower hemoglobin levels, so an increase would not be expected unless treated with erythropoiesis-stimulating agents.
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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