The nurse is assessing the client following the transfusion of 2 units of packed RBCs.
Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding click on the finding again
Laboratory Results
1800
- WBC count 6700/mm3 15.000 to 10.000/mm
- Hemoglobin 12 g/dl (14 to 18 g/dL)
- Hematocrit 36% (40% to 52%)
Vital Signs
1800
- Blood pressure 112/74 mm Hg
- Heart rate 95/min
- Respiratory rate 18/
- Temperature 37.5°C (95°F)
- Oxygen saturation 100% via 2 L/min nasal cannula
Hemoglobin 12 g/dl (14 to 18 g/dL)
Hematocrit 36% (40% to 52%)
Blood pressure 112/74 mm Hg
Heart rate 95/min
Respiratory rate 18/
Temperature 37.5°C (95°F)
Oxygen saturation 100% via 2 L/min nasal cannula
The Correct Answer is ["A","B","C","D","G"]
Rationale for correct findings:
• Hemoglobin 12 g/Dl: The client’s hemoglobin increased from 9.1 g/dL to 12 g/dL following the transfusion of 2 units of packed RBCs. This demonstrates improved oxygen-carrying capacity and correction of anemia, reflecting a positive response to the intervention.
• Hematocrit 36%: The rise in hematocrit from 27% to 36% indicates improved red blood cell volume and overall blood oxygenation. This laboratory improvement confirms that the transfusion effectively restored circulating red blood cells and addressed the client’s prior anemia.
• Blood pressure 112/74 mm Hg: The client’s blood pressure increased from 90/50 mm Hg to 112/74 mm Hg, suggesting improved hemodynamic stability. This indicates better perfusion and a positive response to both transfusion and supportive care.
• Heart rate 95/min: The decrease in heart rate from 118/min to 95/min reflects reduced compensatory tachycardia associated with anemia and hypovolemia. This demonstrates improved cardiovascular status following transfusion.
• Oxygen saturation 100% via 2 L/min nasal cannula: Oxygen saturation improved from 98% on room air to 100% on supplemental oxygen, indicating enhanced oxygen delivery and tissue perfusion. This is an objective sign of recovery from anemia and improved respiratory efficiency.
Rationale for incorrect findings
• Temperature 37.5°C (95°F): The temperature remained essentially unchanged and within normal limits. While important to monitor for infection or transfusion reactions, this finding does not reflect improvement in oxygen-carrying capacity or hemodynamic status.
• Respiratory rate 18/min: The respiratory rate remained stable and within normal limits. Although stability is positive, it does not directly reflect the improvements in hemoglobin, hematocrit, blood pressure, or oxygen saturation resulting from the transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Evaluate why the client was not ambulated.: The first step in addressing a missed delegated task is to assess the reason it was not completed. Understanding whether barriers were related to the AP, client condition, workload, or communication helps the nurse plan corrective action and prevents recurrence.
B. Ambulate the client on behalf of the AP.: While ensuring the client’s needs are met is important, jumping straight to performing the task bypasses assessment of the underlying issue. Immediate action may address the symptom but not the cause of the missed delegation.
C. Supervise the AP performing the task.: Supervision is appropriate for ongoing tasks but is not the first action once a task has already been missed. The nurse must first determine why the task was not completed before implementing supervision.
D. Remind the AP of her assigned tasks.: Reminding the AP without assessing why the task was missed does not address potential systemic or situational barriers. It may be necessary later but is not the initial step in problem resolution.
Correct Answer is C
Explanation
Rationale:
A. Severe abdominal pain: Severe abdominal pain is more characteristic of placental abruption, not placenta previa. Placenta previa typically causes painless bleeding rather than acute abdominal pain, so pain is not a primary expected finding.
B. Polyhydramnios: Excess amniotic fluid is unrelated to placenta previa and is associated with conditions like fetal anomalies, maternal diabetes, or multiple gestation. It is not a typical clinical finding in this condition.
C. Spotting: Painless vaginal bleeding, often bright red and intermittent, is the hallmark sign of placenta previa. Spotting or heavier bleeding occurs as the placenta overlies or partially covers the cervical os, especially during the third trimester.
D. Nausea: Nausea is a nonspecific symptom and is not directly associated with placenta previa. It may occur during normal pregnancy but does not indicate the presence of this placental condition.
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