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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 6,700/mm3 (5,000 to 10,000/mm3)

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/min

Temperature 37.5°C (99.5° F)

Oxygen saturation 100% via 2 L/min nasal cannula

Assessment

1800:

Physical Exam:

General: no distress

HEENT: oropharynx clear, mucous membranes moist and pink

Respiratory: bilateral breath sounds clear

Gl: epigastric tenderness to palpation, no rebound tenderness or guarding Neuro: awake and alert

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Blood pressure 112/74 mm Hg

Heart rate 95/min

Oxygen saturation 100% via 2 L/min nasal cannula

no distress

oropharynx clear, mucous membranes moist and pink

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

Rationale

Findings Indicating Improvement Laboratory Results:

Hemoglobin 12 g/dL (Normal range: 14 to 18 g/dL)

Although the hemoglobin level is still slightly below the normal range (it was 9.1 g/dL prior to the transfusion), it has increased from 9.1 g/dL to 12 g/dL, showing improvement after the blood transfusion. This indicates that the transfusion has helped to raise the hemoglobin level, improving oxygen-carrying capacity.

Hematocrit 36% (Normal range: 40% to 52%)

The hematocrit level has also increased from 27% to 36%. While still below normal, this is an improvement, suggesting the transfusion is starting to correct the client’s anemia and restore normal blood volume.

Vital Signs:

Blood Pressure 112/74 mm Hg

The blood pressure has improved significantly from 76/45 mm Hg (at 1200) and 78/49 mm Hg (at 1230). An increase in blood pressure to 112/74 mm Hg indicates the client is now hemodynamically stable, and the transfusion has helped to address the hypotension. The blood pressure is now in a normal range (typically around 120/80 mm Hg), and it is no longer dangerously low.

Heart Rate 95/min

The heart rate has decreased from 118/min and 121/min (at earlier times) to 95/min. This drop

indicates that the client’s heart is not having to work as hard to compensate for the low blood volume,

suggesting improvement in circulatory status.

Oxygen Saturation 100% via 2 L/min nasal cannula

Oxygen saturation is now normal at 100%. This is an improvement compared to the previous status of 98% on room air, which indicates that the client is now receiving adequate oxygenation, and the supplemental oxygen may be effectively maintaining oxygen levels.

Physical Exam:

General: No distress

The client is no longer in apparent distress, which is an important sign of improvement. Prior to the transfusion, the client was described as diaphoretic and uncomfortable, but now the client is stable and not in distress.

HEENT: Oropharynx clear, mucous membranes moist and pink

The mucous membranes are now moist and pink, which suggests adequate hydration and oxygenation. This is an improvement, as the previous finding indicated the client’s mucous membranes were pale (which can be a sign of anemia or dehydration).

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Instructing the client to avoid coughing during the procedure is important to prevent disrupting the needle placement during the thoracentesis.
B. The client should not be positioned in the prone position; instead, they are typically positioned upright and leaning forward to facilitate access to the pleural space.
C. Positioning the client on the affected side post-procedure may not be necessary unless ordered by the provider. Standard care includes positioning the client in an upright position after the procedure to promote lung expansion.
D. The client is generally not NPO for thoracentesis unless specified by the healthcare provider. The focus should be on ensuring comfort and informing the client about the procedure.

A. Current medications B. Hemoglobin and hematocrit C. Stool results D. WBC count E. Blood pressure F. Temperature G. Respiratory rate H. Heart rate

Correct Answer is ["B","C","E","F","H"]

Explanation

Findings Requiring Immediate Follow-Up:

B. Hemoglobin and Hematocrit:
The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly lower than normal (14-18 g/dL for hemoglobin and 40-52% for hematocrit). This is indicative of anemia, which could be due to chronic blood loss, potentially from a gastrointestinal source (given the history of dark, tarry stool). Anemia can lead to symptoms such as weakness, dizziness, and fatigue, and if severe, it could lead to hypovolemic shock.
C. Stool results:
The hemoccult stool test is positive, indicating gastrointestinal bleeding, likely from an upper GI source (e.g., ulcers or gastritis). Combined with the client's symptoms of gnawing abdominal pain, a burning sensation radiating to the back, and a history of dark, tarry stools (which suggests melena), this is concerning for a peptic ulcer disease (PUD) or even a gastric ulcer. This finding warrants immediate follow-up to evaluate the cause and assess for complications such as active bleeding or perforation.
E. Blood Pressure:
The client’s blood pressure is 90/50 mm Hg, which is hypotensive and likely a sign of hypovolemia due to blood loss (from the GI bleeding indicated by the positive hemoccult test). Hypotension is a concerning finding, especially in a client with anemia and symptoms of abdominal distress. Immediate intervention is needed to address the blood pressure and prevent further complications, such as shock.
F. Temperature:
The client’s temperature is 37.5°C (99.5°F), which is slightly elevated (normal is typically 36.1-37.2°C or 97°F-99°F). While not dramatically high, a low-grade fever could suggest an infection (e.g., due to H. pylori, which is positive in this client, or an associated gastric infection or inflammation). In this case, it could indicate a need for monitoring, as infections can exacerbate symptoms and complications, particularly in the setting of a GI ulcer or bleeding.
H. Heart Rate:
The client's heart rate is elevated at 118 beats per minute (tachycardia). Tachycardia in this setting could be a compensatory mechanism for hypovolemia due to the blood loss suggested by the low hemoglobin/hematocrit and positive stool test. The elevated heart rate could also be a sign of pain, anxiety, or systemic response to the GI distress. Regardless, tachycardia is a significant finding in the context of hypotension and anemia and requires immediate follow-up to prevent cardiovascular complications.

Findings That Do Not Require Immediate Follow-Up:
A. Current Medications:
The client is taking Ibuprofen, which is a nonsteroidal anti-inflammatory drug (NSAID). While NSAIDs can cause gastrointestinal irritation and increase the risk of bleeding (particularly in the presence of ulcers), the client’s current medications do not require immediate follow-up as a standalone issue. However, if a diagnosis of ulcer or gastrointestinal bleeding is confirmed, the use of NSAIDs should be discontinued.
D. WBC Count:
The client's WBC count is 6,700/mm³, which is within the normal range (5,000-10,000/mm³). This does not indicate infection or significant inflammation. Given the context of the client’s symptoms and lab results, there is no immediate concern with the WBC count at this time.
G. Respiratory Rate:
The client’s respiratory rate is 18/min, which is within the normal range (12-20 breaths per minute for adults). There is no indication of respiratory distress or abnormal breathing patterns in this patient, so no immediate follow-up is required in this area.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["B","C","E","F","H"]

Explanation

The nurse continues to care for the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

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