A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion?

The client's lung sounds remain clear during the transfusion.

The client's blood pressure increases to 140/85 mm Hg following the transfusion

The client's hemoglobin level increases following the transfusion.

The client is afebrile during the transfusion.

Answer and Explanation

The Correct Answer is C

Rationale:

A. The client's lung sounds remain clear during the transfusion: Clear lung sounds indicate the absence of fluid overload or pulmonary complications, which is a safety indicator, but it does not reflect the effectiveness of the transfusion in improving oxygen-carrying capacity.

B. The client's blood pressure increases to 140/85 mm Hg following the transfusion: A sudden rise in blood pressure could indicate fluid overload or a transfusion reaction, not necessarily a positive response to the transfusion.

C. The client's hemoglobin level increases following the transfusion: An increase in hemoglobin indicates that the transfused red blood cells have effectively raised the client’s oxygen-carrying capacity, demonstrating a positive therapeutic response.

D. The client is afebrile during the transfusion: Remaining afebrile indicates the absence of a febrile transfusion reaction, which is a safety measure, but it does not show that the transfusion achieved its therapeutic goal.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

Rationale:

Hallucinations: Auditory hallucinations, such as the client reporting listening to unseen others, are a hallmark symptom of psychosis. This indicates a break from reality and requires close psychiatric monitoring.
Lack of sleep: Sleep deprivation is common in manic episodes due to heightened energy and decreased need for rest. Chronic sleep loss in mania can exacerbate irritability, impulsivity, and cognitive impairment.
Pressured speech: Rapid, loud, and continuous speech is characteristic of mania. It reflects heightened energy, distractibility, and impaired judgment, often making communication difficult for caregivers.
Excessive spending habits: Impulsive financial decisions and risky behaviors, such as giving away large sums of money, are indicative of manic episodes. These behaviors can have serious social and financial consequences.
Disorganized thought process: Disorganized thinking can occur in both psychosis and mania. In psychosis, it may manifest as illogical or tangential thought patterns, while in mania, racing thoughts can disrupt coherent speech and planning.

A. "Keep objects away from your center of gravity while lifting." B. "Keep your feet together to provide a tight base of support." C. "Tighten abdominal muscles to improve balance." D. "Bend at the waist when lifting objects from the floor."

Correct Answer is C

Explanation

A. "Keep objects away from your center of gravity while lifting.": Lifting objects away from the body increases strain on the back and risks injury. Objects should be kept close to the body to reduce musculoskeletal stress.

B. "Keep your feet together to provide a tight base of support.": A narrow stance decreases stability and increases the risk of losing balance. Proper lifting requires a wide, stable base with feet shoulder-width apart.

C. "Tighten abdominal muscles to improve balance.": Engaging the core stabilizes the spine, maintains proper posture, and helps prevent back injuries during lifting. This is an important ergonomic technique.

D. "Bend at the waist when lifting objects from the floor.": Bending at the waist places excessive strain on the lower back. Proper lifting technique involves bending at the knees and hips while keeping the back straight.

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A nursery nurse is attending the birth of a post-term infant.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing

and .

View Question and Answer

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A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse continues to care for the client. For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurses is the nurse demonstrating?

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The nurse reviews the entries in the medical record. Exhibits The nurse is preparing the client for a blood transfusion, which of the following actions should the nurse take? Select all that apply.

A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

A nursery nurse is attending the birth of a post-term infant. Exhibits Drag words from the choices below to fill in each blank in the following sentence. Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing dropdown and dropdown.

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