The nurse is assessing the client following the transfusion of 2 units of packed RBCs.
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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 C
Explanation
Rationale:
A. “I should advise a client about what I feel to be his best health care decision.": Advocacy involves supporting the client’s choices and rights, not imposing the nurse’s personal opinions. Advising based on personal beliefs undermines the client’s autonomy and is not consistent with professional advocacy.
B. "I should not advocate for a client unless he is able to ask me himself.": Client advocacy includes speaking up on behalf of clients who cannot voice their own needs, such as those who are incapacitated or vulnerable. Waiting for the client to ask would neglect the nurse’s responsibility to protect and support the client.
C. “I will intervene if there is a conflict between a client and his provider.": Advocacy involves intervening when a client’s rights, preferences, or safety are at risk, including resolving conflicts with providers. This demonstrates understanding of the nurse’s role in ensuring the client’s voice is heard and needs are met.
D. “I will inform a client that his family should help make his health care decisions.": While family input can be important, the client’s autonomy takes priority. Encouraging family decision-making over the client’s choices does not reflect proper advocacy and may compromise the client’s rights.
Correct Answer is C
Explanation
Rationale:
A. The nurse should dispose of the ampule in the trash can: Glass ampules are considered sharps and must be disposed of in a designated sharps container to prevent injury and maintain safety. Throwing them in regular trash is unsafe and violates standard precautions.
B. The nurse should use the same needle to draw up and inject the client: Using the same needle can introduce glass particles or contamination into the client’s tissue. A new sterile needle should be used for injection after withdrawing the medication to ensure safety and sterility.
C. The nurse should use a filter needle to withdraw the medication: A filter needle is designed to prevent small glass shards from being drawn into the syringe when breaking the ampule. This action protects the client from injury and ensures that the medication administered is free from particulate matter.
D. The nurse should break the neck of the ampule toward their body: The ampule should always be broken away from the body to prevent injury from glass shards. Breaking it toward oneself increases the risk of cuts and contamination, making it an unsafe practice.
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