The nurse is collecting data from 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/mm (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)
O2 saturation 100% 2 L/min O2 via nasal cannula
Assessment:
1800:
Physical Exam
General: no distress
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pink
Respiratory: bilateral breath sounds clear
Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding
Neurologic: awake and alert
WBC count 6,700/mm (5,000 to 10,000/mm3)
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/min
Temperature 37.5° C (99.5° F)
O2 saturation 100% 2 L/min O2 via nasal cannula
oropharynx clear, mucous membranes moist and pink
bilateral breath sounds clear
The Correct Answer is ["A","B","C","D","E","H","J"]
- WBC count 6,700/mm³ is unchanged from previous readings, remaining within normal limits, indicating no new or worsening infection or inflammatory response.
- Hemoglobin 12 g/dL represents a significant increase from the previous value of 7.8 g/dL, demonstrating successful red blood cell transfusion and improvement in oxygen-carrying capacity.
- Hematocrit 36% is also markedly improved from 24%, further confirming correction of anemia following transfusion.
- Blood pressure 112/74 mm Hg has increased from a low of 76/45 mm Hg, indicating improved circulatory status and perfusion following fluid resuscitation and transfusion.
- Heart rate 95/min is a decrease from previous tachycardic values (121/min), suggesting stabilization of hemodynamics and resolution of compensatory response to anemia and hypotension.
- Oxygen saturation 100% on 2 L/min O₂ via nasal cannula confirms adequate oxygenation, demonstrating improved hemoglobin levels and effective oxygen delivery.
- Respiratory: bilateral breath sounds clear confirms stable respiratory function, showing no complications such as fluid overload or transfusion-related lung injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "If I keep gaining weight, I will be miserable." Expressing anxiety about weight gain reflects a lack of emotional readiness and acceptance regarding the physical changes that accompany pregnancy.
B. "I cannot believe I got pregnant. We really weren't even trying to have a baby." Indicating surprise suggests a lack of preparation for the emotional and practical aspects of pregnancy. This reflects that the client may not have fully accepted the reality of the situation.
C. "I understand that hormonal changes can cause me to be happy one minute and sad the next." Recognizing and accepting the emotional fluctuations that can occur during pregnancy due to hormonal changes indicates a level of emotional preparation for the journey ahead.
D. "This baby will totally change my lifestyle, and I am not sure I am ready for all of this." Acknowledging the impact of having a baby on lifestyle is important, but expressing uncertainty suggests that the client may still be struggling with the implications of becoming a parent.
Correct Answer is D
Explanation
A. Nausea. Epinephrine is not primarily used to treat nausea. It is a sympathomimetic medication that works by stimulating alpha and beta receptors, mainly to counteract severe allergic reactions, including respiratory distress and hypotension. Nausea is not a primary indication for its use.
B. Hand tremors. Epinephrine can cause hand tremors as a side effect due to its stimulant effects on the nervous system. However, it is not used to treat tremors, and the presence of tremors after administration is a common physiological response rather than a therapeutic effect.
C. Hyperglycemia. Epinephrine can increase blood glucose levels by stimulating glycogenolysis and inhibiting insulin secretion. However, it is not used for treating hyperglycemia, and its effects on glucose metabolism are incidental rather than a primary therapeutic action.
D. Shortness of breath. Epinephrine is commonly used to treat anaphylaxis, which can cause airway swelling and bronchospasm leading to shortness of breath. By stimulating beta-2 receptors, epinephrine relaxes bronchial smooth muscles, improving airflow and reducing respiratory distress.
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