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The nurse is assessing the client following the transfusion of 2 units of packed RBCs.

Exhibits

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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. "Can you tune out the voices by listening to music?": This question focuses on coping strategies, which is important, but it is not the immediate priority. The nurse must first assess the content of the hallucinations to determine potential risk.

B. "Are you also seeing unusual persons or things?": Assessing for visual hallucinations is useful, but the client is currently experiencing auditory command hallucinations. Immediate focus should be on the commands to ensure safety.

C. "What are the voices telling you to do?": Determining the content of the voices is the priority because command hallucinations may instruct the client to harm themselves or others. Assessing risk and ensuring safety comes before exploring coping or additional symptoms.

D. "Do the voices cause you to feel anxious?": Assessing emotional response is relevant, but it is secondary to understanding whether the hallucinations pose a safety risk to the client or others.

A. Remove stopcocks from IV tubing B. Disinfect and powder any latex products before use. C. Tape stockinet over monitoring devices and cords. D. Schedule the client as the last surgery of the day.

Correct Answer is C

Explanation

Rationale:

A. Remove stopcocks from IV tubing: Removing stopcocks is not necessary and may compromise IV line function. The priority is to prevent contact with latex-containing components, not to eliminate all IV hardware, as many are latex-free.

B. Disinfect and powder any latex products before use: Powdered latex products increase the risk of airborne latex particles, which can trigger severe allergic reactions. Disinfecting or using powdered latex items is unsafe for clients with latex sensitivity and should be avoided entirely.

C. Tape stockinet over monitoring devices and cords: Covering monitoring devices, cords, and other equipment with a barrier such as stockinet prevents direct contact with latex-containing components. This reduces the risk of an allergic reaction during surgery while allowing the necessary monitoring and functionality to continue safely.

D. Schedule the client as the last surgery of the day: While scheduling considerations may be made to reduce exposure to residual latex or disinfectants, the timing of surgery is not the primary strategy for preventing a reaction. The focus should be on removing or isolating all latex-containing items from the environment.

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Naxlex Comprehensive Predictor Exams

A nurse in an acute mental health facility is assessing a client who is experiencing auditory command hallucinations. Which of the following questions should the nurse ask first?

Correct Answer is C

Explanation

A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following strategies is appropriate for this client?

Correct Answer is C

Explanation

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