The nurse is collecting data from 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 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

A. Trousseau's sign indicates hypocalcemia, not hyperkalemia. It is assessed by inflating a blood pressure cuff around the upper arm and observing for muscle spasms in the hand and wrist, which is not related to potassium levels.
B. Irregular heart rate. Hyperkalemia can lead to cardiac dysrhythmias due to its effect on myocardial excitability and conduction. Elevated potassium levels can cause changes in the electrocardiogram (ECG), such as peaked T waves and prolonged PR intervals, which may result in an irregular heart rate and can be life-threatening if not addressed.
C. Hyperactive reflexes are typically associated with conditions such as hypercalcemia or neurological disorders, not hyperkalemia. Hyperkalemia can lead to decreased neuromuscular excitability and may present with muscle weakness or decreased reflexes.
D. Dry mucous membranes is more indicative of dehydration or a fluid volume deficit rather than hyperkalemia. Clients with renal failure may have fluid retention and edema due to impaired kidney function, which is contrary to the presentation of dry mucous membranes.

A. Peeling of the hands and feet is not a common manifestation of pertussis. This symptom is typically associated with other conditions, such as Kawasaki disease or toxic shock syndrome, rather than an infection caused by Bordetella pertussis.
B. Beefy, red tongue is usually seen in conditions like scarlet fever or certain nutritional deficiencies, such as vitamin B12 deficiency. It is not characteristic of pertussis and does not align with the typical clinical presentation of this respiratory illness.
C. Fever is a common manifestation of pertussis, especially in the early stages. The child may present with a mild to moderate fever as the immune system responds to the infection. Fever can help in distinguishing pertussis from other respiratory illnesses, especially in conjunction with the classic coughing fits.
D. Facial erythema is not typically seen in pertussis. While some flushing may occur during intense coughing episodes, it is not a primary symptom. Pertussis is more characterized by severe coughing fits, the distinctive "whoop" sound during inspiration, and potential vomiting after coughing.