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. Beneficence. Beneficence refers to the ethical obligation to promote the well-being of clients and take actions that benefit them. While providing medication education supports the client's health, the primary ethical principle demonstrated in truthfully explaining adverse effects is veracity, not beneficence.
B. Justice. Justice involves fairness in the distribution of resources, treatment, and care. It ensures that all clients receive equitable care regardless of personal or socioeconomic differences. While justice is a fundamental ethical principle, it does not directly relate to truthfulness in medication education.
C. Veracity. Veracity is the ethical principle of honesty and truthfulness in communication with clients. By truthfully informing the client about the adverse effects of their prescribed medications, the nurse upholds veracity, ensuring the client has accurate information for informed decision-making.
D. Autonomy. Autonomy refers to the client’s right to make informed decisions about their care. While providing truthful information supports autonomy, the ethical concept the nurse demonstrates in this scenario is veracity, as the focus is on truthfully sharing medication information.

A. Positive Chvostek's sign. Hypocalcemia increases neuromuscular excitability, leading to involuntary twitching of facial muscles when the facial nerve is tapped. This sign is a well-known indicator of calcium deficiency and reflects heightened nerve sensitivity.
B. Hypotension. While severe hypocalcemia can affect cardiovascular function, hypotension is not a primary or consistent finding. More commonly, calcium imbalances affect muscle contractions rather than directly causing low blood pressure.
C. Confusion. Hypocalcemia can cause neurological symptoms, but confusion is more common in severe or prolonged cases. Early manifestations are usually neuromuscular, such as tetany or muscle cramps, rather than cognitive impairment.
D. Positive Babinski reflex. This reflex is associated with upper motor neuron dysfunction and neurological disorders rather than electrolyte imbalances like hypocalcemia. Calcium deficiency primarily affects peripheral nerves and muscle excitability.