A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

Hemoglobin 14.9 g/dL

WBC count 12.000/mm

Potassium 48 mEq

BUN 18 mg/dL

Answer and Explanation

The Correct Answer is A

A. Correct. A hemoglobin level of 14.9 g/dL indicates that the client has an adequate amount of oxygen-carrying capacity in the blood, which is the goal of blood transfusion therapy.
B. Incorrect. A WBC count of 12,000/mm3 is slightly elevated and may indicate an infection or inflammation, which are not related to blood transfusion therapy.
C. Incorrect. A potassium level of 48 mEq/L is dangerously high and may cause cardiac arrhythmias, muscle weakness, or paralysis. This is not an expected outcome of blood transfusion therapy and may indicate hemolysis or renal impairment.
D. Incorrect. A BUN level of 18 mg/dL is within the normal range and does not reflect the effectiveness of blood transfusion therapy.

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Correct Answer is C

Explanation

Choice A rationale:

Massaging the legs before applying the stockings is not advisable. Vigorous massage can dislodge clots in patients with DVT, leading to serious complications like pulmonary embolism. It is essential to handle the legs gently and follow the proper procedure for applying antiembolitic stockings.

Choice B rationale:

Folding the stockings at the top if they are too long is not recommended. Altering the stockings in this way can create uneven pressure, reducing their effectiveness in preventing DVT. It is crucial to choose the correct size of stockings to ensure proper compression and prevention of complications.

Choice C rationale:

Measuring the legs with a tape measure to determine the stocking size is the correct action. Proper sizing is essential to ensure the stockings fit the patient correctly and provide the appropriate level of compression. Ill-fitting stockings can be ineffective and may even cause harm, such as skin abrasions or impeded circulation.

Choice D rationale:

Removing the stockings every 24 hours is unnecessary unless there is a specific medical indication to do so. Continuous wear of antiembolitic stockings is generally recommended to provide consistent compression and prevent deep-vein thrombosis (DVT)

A. aPTT B. PT C. INR D. WBC count

Correct Answer is A

Explanation

- A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.

- B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.

- C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.

- D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.

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A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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