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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Free Nursing Study Resources

Correct Answer is ["A","B","F","H","I","L"]

Explanation

Rationale for correct choices:

Temperature 38.2° C (100.8° F): An elevated temperature in the postpartum period may indicate infection, particularly given the prolonged rupture of membranes and cesarean birth. Early recognition is essential to prevent progression to sepsis.
Heart rate 104/min: Tachycardia can be an early sign of infection or postpartum hemorrhage. In combination with fever and elevated WBC, this warrants prompt evaluation.
Client reports feeling unwell: The client’s report of illness is the first indicator of an ongoing disease process which warrants further evaluation, coupled by other findings, this indicates that there is something wrong.
WBC count 33,000/mm³: This is markedly elevated beyond the normal postpartum range and indicates a possible systemic infection. This finding requires immediate intervention and notification of the provider.
Fundus boggy but firmed with massage: A boggy uterus suggests uterine atony, which increases the risk of postpartum hemorrhage. Continuous monitoring is needed to prevent excessive blood loss.
Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a sign of endometritis or uterine infection. Early identification and treatment reduce the risk of sepsis and further complications.

Rationale for incorrect choices:

Vital Signs Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97% on room air: This is within normal limits and does not indicate respiratory compromise at this time. Blood pressure is within normal postpartum range; no immediate intervention is needed. Oxygen saturation is adequate and does not require urgent follow-up.
Breast firmness with moderate nipple discomfort: These findings are consistent with normal lactation and engorgement, and do not indicate an immediate complication.
Surgical incision well-approximated with slight edema: Mild edema without redness or drainage is expected postoperatively and does not require immediate intervention.
No bowel movement since birth, hypoactive bowel sounds: While monitoring is necessary for constipation, this is a common postpartum finding, especially after surgery and opioid use, and does not require urgent intervention.

A. Splitting behavior B. Emotional lability C. Self-centered behavior D. Suspicious of others

Correct Answer is B

Explanation

A. Splitting behavior: Splitting, or viewing people as all good or all bad, is characteristic of borderline personality disorder rather than histrionic personality disorder. It reflects difficulty integrating positive and negative aspects of self and others.

B. Emotional lability: Clients with histrionic personality disorder often display rapidly shifting emotions, exaggerated expression of feelings, and attention-seeking behaviors. Emotional lability is a hallmark feature, making this an expected manifestation.

C. Self-centered behavior: While clients with histrionic personality disorder may seek attention, overt self-centeredness and grandiosity are more characteristic of narcissistic personality disorder rather than histrionic traits.

D. Suspicious of others: Suspiciousness and distrust are typical of paranoid personality disorder. Clients with histrionic personality disorder are generally sociable and seek approval rather than displaying pervasive mistrust.

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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

Correct Answer is ["A","B","F","H","I","L"]

Explanation

A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

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