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

 

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.