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 D

Explanation

Rationale:

A. Implement activities that promote the client's self-esteem: While boosting self-esteem can support smoking cessation, it is not the first priority. The nurse must first assess the client’s current coping strategies to tailor the cessation plan.

B. Offer a list of smoking cessation support groups: Providing resources is helpful, but without assessing the client’s needs and coping methods first, the support may not be appropriately matched to the client’s situation.

C. Provide education about the dangers of smoking: Education is important, but most clients are already aware of the health risks. Effective teaching requires first understanding the client's motivation and coping mechanisms.

D. Determine the client's coping methods: Assessment is always the initial step in the nursing process. Identifying how the client currently manages stress will help the nurse create an individualized and effective cessation plan.

A. Speech-language pathologist B. Social worker C. Respiratory therapist D. Occupational therapist

Correct Answer is A

Explanation

A. Speech-language pathologist: Speech-language pathologists (SLPs) specialize in evaluating and treating swallowing disorders (dysphagia). They can assess the client’s swallowing ability, recommend appropriate diet modifications, and provide strategies to reduce choking risk.

B. Social worker: Social workers provide support for psychosocial needs, discharge planning, and community resources, but they do not assess or manage swallowing difficulties. Referral to a social worker may be appropriate for broader care needs but not for dysphagia.

C. Respiratory therapist: Respiratory therapists focus on airway management, ventilation, and pulmonary function. While they can assist if aspiration leads to respiratory complications, they do not primarily assess swallowing function.

D. Occupational therapist: Occupational therapists help clients with activities of daily living and adaptive equipment. Although they may assist with feeding techniques or positioning, they are not specialized in assessing or treating swallowing disorders.

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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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