A nurse is reviewing the baseline assessment and history of a client.
Based on the assessment findings of lungs clear to auscultation, temperature 98.2 F, blood pressure 132/80, pulse 92, and respirations 20, which of the following would be an expected finding?

An acute hemolytic reaction.

Shortness of breath and crackles in the lungs.

An increase in hemoglobin and hematocrit.

A decrease in platelet count.

Answer and Explanation

The Correct Answer is C

Choice A rationale

An acute hemolytic reaction is a life threatening complication of blood transfusions caused by ABO incompatibility. Clinical manifestations typically include fever, chills, hypotension, tachycardia, and excruciating lower back pain. The assessment findings provided show a normal temperature of 98.2 F and a stable blood pressure of 132/80, which are inconsistent with the systemic inflammatory response and vascular collapse seen in hemolysis. Therefore, a hemolytic reaction would not be an expected finding based on these stable baseline vital signs.

Choice B rationale

Shortness of breath and crackles in the lungs are primary indicators of fluid volume overload or pulmonary edema. The baseline assessment explicitly states that the lungs are clear to auscultation and the respiratory rate is within the normal range of 12 to 20 breaths per minute at 20. If a client were experiencing circulatory overload, the nurse would expect to hear adventitious breath sounds and observe an increased work of breathing, neither of which is present in the current clinical data.

Choice C rationale

An increase in hemoglobin and hematocrit is the physiological goal of a red blood cell transfusion. Red blood cells are administered to improve oxygen carrying capacity in patients with anemia or acute blood loss. Normal hemoglobin ranges are 14 to 18 g/dL for men and 12 to 16 g/dL for women, while hematocrit ranges from 42 percent to 52 percent for men and 37 percent to 47 percent for women. These values should rise proportionately following a successful and uncomplicated transfusion.

Choice D rationale

A decrease in platelet count, known as thrombocytopenia, is not a typical or expected outcome of a standard red blood cell transfusion. Platelets are responsible for primary hemostasis and a normal count ranges from 150,000 to 400,000 cells/mm. While some dilutional effects can occur during massive transfusion protocols, a routine unit of packed red blood cells should not cause a drop in platelet levels. Such a finding might instead suggest an underlying pathology like disseminated intravascular coagulation or heparin induced thrombocytopenia.

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Correct Answer is C

Explanation

Choice A rationale

Encouraging independence in activities of daily living is a fundamental therapeutic goal for patients with Parkinson disease. This neurological disorder involves the progressive degeneration of dopaminergic neurons in the substantia nigra, leading to tremors and bradykinesia. When the assistant encourages self-feeding, they promote fine motor coordination and preserve the client's autonomy. This action does not require intervention because it aligns with the rehabilitative focus of maintaining functional abilities for as long as possible during disease progression.

Choice B rationale

Clients with Parkinson disease often develop a shuffling gait and a tendency to look down, which shifts their center of gravity and increases the risk of falls. Instructing the client to look up and toward the horizon rather than at their feet helps maintain an upright posture and improves balance. This is a standard safety intervention used to counteract the postural instability and truncal hyperflexion characteristic of the disease. Therefore, the assistant is providing appropriate safety guidance during ambulation.

Choice C rationale

This action requires intervention because performing a complete bath for a client who is capable of participation fosters unnecessary dependence. In Parkinson's care, the focus is on maintaining the client's ability to perform self-care to prevent muscle atrophy and functional decline. The assistant should instead provide the necessary tools and allow the client to perform as much of the hygiene routine as possible. Passive care contradicts the goal of maximizing the client's physical and psychological well-being.

Choice D rationale

Assisting a client with Parkinson disease during ambulation is a vital safety measure to prevent falls. The disease often causes freezing of gait and impaired postural reflexes, making the transition from sitting to standing and walking precarious. Providing physical support ensures the client remains stable while moving between the bed and the bathroom. Since this action directly addresses the high fall risk associated with the client's motor deficits, it is an appropriate task for the assistant.

A. Artificial rupture of membranes. B. Placenta abruption. C. Fetal scalp electrode application. D. Amniocentesis. E. Chorionic villus sampling.

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale

Artificial rupture of membranes, also known as an amniotomy, is a procedure where the amniotic sac is intentionally punctured to induce or augment labor. While it involves a physical intervention, it does not typically involve the type of placental or uterine wall trauma that leads to significant fetomaternal hemorrhage. Therefore, it is not a standard, primary indication for the administration of RhoGAM unless it was accompanied by other complications that resulted in the mixing of fetal and maternal blood.

Choice B rationale

Placenta abruption involves the premature separation of the placenta from the uterine wall, which often causes significant bleeding at the site of attachment. This event creates a high risk for fetomaternal hemorrhage, where Rh positive fetal red blood cells enter the Rh negative mother's circulation. To prevent the mother from developing antibodies against the D antigen, RhoGAM must be administered. This prevents hemolytic disease of the newborn in future pregnancies by providing passive immunity that clears fetal cells.

Choice C rationale

The application of a fetal scalp electrode is a method of internal fetal monitoring that involves attaching a small spiral electrode to the fetal presenting part. While this causes a minor puncture in the fetal skin, it does not usually result in a significant enough breach of the placental barrier to cause maternal sensitization. Consequently, this procedure is generally not considered an indication for RhoGAM administration, as the risk of maternal exposure to fetal blood during this specific process is extremely low.

Choice D rationale

Amniocentesis is a diagnostic procedure where a needle is inserted through the maternal abdomen and into the uterine cavity to withdraw amniotic fluid. Because the needle must pass through the uterine environment and potentially near the placenta, there is a distinct risk of causing a small amount of fetal blood to enter the maternal bloodstream. In Rh negative mothers, this potential exposure necessitates the administration of RhoGAM to prevent the formation of permanent anti-D antibodies that could harm future fetuses.

Choice E rationale

Chorionic villus sampling is a prenatal test performed in early pregnancy that involves taking a sample of placental tissue for genetic testing. Similar to amniocentesis, this invasive procedure carries a significant risk of fetomaternal hemorrhage because it directly disrupts the placental structure. Any time there is a risk of fetal cells entering maternal circulation in an Rh negative individual, RhoGAM is required to provide immunoprophylaxis and protect against the development of Rh isoimmunization, ensuring the safety of subsequent pregnancies

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A nurse is reviewing the baseline assessment and history of a client. Based on the assessment findings of lungs clear to auscultation, temperature 98.2 F, blood pressure 132/80, pulse 92, and respirations 20, which of the following would be an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assigned to care for a client with Parkinson's disease. While supervising an unlicensed assistive personnel (UAP), which action by the UAP requires intervention by the nurse?

Correct Answer is C

Explanation

The nurse is reviewing the health record for several pregnant clients with Rh negative blood. Which of the following is/are an indication(s) for the nurse to administer RhoGAM? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

The nurse is caring for a pregnant client during the first prenatal visit. Prior to obtaining prenatal lab work the client asks the nurse, "Why do I need a rubella screening? I was already vaccinated.”. What explanation by the nurse is most accurate?

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A clinic sees several clients with sexually transmitted infections. Which diseases would the nurse be required to report to the health department? (Select all that apply).

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In addition to the regular pregnancy diet and prenatal vitamins and minerals, which supplements would the nurse educate the pregnant client with a history of ventricular septal defect repair to take?

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A client referred to the eating disorders clinic is diagnosed with Bulimia Nervosa. For which physical manifestations should a nurse assess? (Select all that apply.)

A nurse is reviewing the baseline assessment and history of a client.
Based on the assessment findings of lungs clear to auscultation, temperature 98.2 F, blood pressure 132/80, pulse 92, and respirations 20, which of the following would be an expected finding?