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The nurse is assessing the client following the transfusion of 2 units of packed RBCs.

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/mm3 (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)

Oxygen saturation 100% via 2 L/min nasal cannula

Assessment

1800:

Physical Exam:

General: no distress

HEENT: oropharynx clear, mucous membranes moist and pink

Respiratory: bilateral breath sounds clear

Gl: epigastric tenderness to palpation, no rebound tenderness or guarding Neuro: awake and alert

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Blood pressure 112/74 mm Hg

Heart rate 95/min

Oxygen saturation 100% via 2 L/min nasal cannula

no distress

oropharynx clear, mucous membranes moist and pink

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

Rationale

Findings Indicating Improvement Laboratory Results:

Hemoglobin 12 g/dL (Normal range: 14 to 18 g/dL)

Although the hemoglobin level is still slightly below the normal range (it was 9.1 g/dL prior to the transfusion), it has increased from 9.1 g/dL to 12 g/dL, showing improvement after the blood transfusion. This indicates that the transfusion has helped to raise the hemoglobin level, improving oxygen-carrying capacity.

Hematocrit 36% (Normal range: 40% to 52%)

The hematocrit level has also increased from 27% to 36%. While still below normal, this is an improvement, suggesting the transfusion is starting to correct the client’s anemia and restore normal blood volume.

Vital Signs:

Blood Pressure 112/74 mm Hg

The blood pressure has improved significantly from 76/45 mm Hg (at 1200) and 78/49 mm Hg (at 1230). An increase in blood pressure to 112/74 mm Hg indicates the client is now hemodynamically stable, and the transfusion has helped to address the hypotension. The blood pressure is now in a normal range (typically around 120/80 mm Hg), and it is no longer dangerously low.

Heart Rate 95/min

The heart rate has decreased from 118/min and 121/min (at earlier times) to 95/min. This drop

indicates that the client’s heart is not having to work as hard to compensate for the low blood volume,

suggesting improvement in circulatory status.

Oxygen Saturation 100% via 2 L/min nasal cannula

Oxygen saturation is now normal at 100%. This is an improvement compared to the previous status of 98% on room air, which indicates that the client is now receiving adequate oxygenation, and the supplemental oxygen may be effectively maintaining oxygen levels.

Physical Exam:

General: No distress

The client is no longer in apparent distress, which is an important sign of improvement. Prior to the transfusion, the client was described as diaphoretic and uncomfortable, but now the client is stable and not in distress.

HEENT: Oropharynx clear, mucous membranes moist and pink

The mucous membranes are now moist and pink, which suggests adequate hydration and oxygenation. This is an improvement, as the previous finding indicated the client’s mucous membranes were pale (which can be a sign of anemia or dehydration).

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Delusions can contribute to aggressive behavior, but they are not as strong a predictor of future violence as a history of violent behavior.
B. While a history of incarceration may be a contributing factor, it does not predict future violence as strongly as previous violent behavior.
C. Previous violent behavior is the best predictor of future violence because it indicates a pattern of behavior that is likely to continue.
D. While male gender is a factor that may be associated with violence, it is not as predictive as a history of violent behavior.

A. Apply warm compresses to the incision site. B. Administer enema to relieve constipation. C. Irrigate indwelling urinary catheter with 50 mL of normal saline. D. Place a blanket roll under the client's knees while in bed. E. Maintain bed rest for 2 days postoperatively.

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

Explanation

1. Apply warm compresses to the incision site
Contraindicated
Applying warm compresses directly to the surgical site, especially in a perineal prostatectomy, could potentially increase the risk of infection or cause increased swelling in the surgical area. The incision site is still healing, and local heat could increase blood flow, which might lead to complications like bleeding or infection.
2. Administer enema to relieve constipation

Anticipated
The client reports abdominal cramping and small, hard, painful bowel movements, which are signs of constipation. Enemas are commonly used to relieve constipation and to prevent straining that could stress the perineal surgical site or cause hemorrhoidal irritation. The use of an enema is appropriate in this case to help alleviate the client's symptoms.
3. Irrigate indwelling urinary catheter with 50 mL of normal saline

Anticipated
After prostatectomy, clients often have an indwelling urinary catheter for urinary drainage. Irrigating the catheter can help prevent clogging and maintain proper drainage. Normal saline is a sterile solution and would help ensure the catheter is patent, which is particularly important for preventing urinary retention or infection.
4. Place a blanket roll under the client's knees while in bed

Anticipated
Placing a blanket roll under the client’s knees helps to maintain a comfortable position, which can promote venous return and reduce pressure on the perineum and lower back. This position is also beneficial for alleviating perineal pain after prostate surgery.
5. Maintain bed rest for 2 days postoperatively

Contraindicated
The client has already demonstrated the ability to ambulate independently and transfer out of bed to a chair. Prolonged bed rest after surgery is generally discouraged unless there are specific complications (e.g., excessive bleeding, infection). Early ambulation is encouraged to prevent DVT, promote circulation, and prevent complications such as atelectasis and constipation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

Correct Answer is C

Explanation

A nurse is caring for a postoperative client following a perineal prostatectomy. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

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

Explanation

A nurse is caring for a client in an acute care setting. Exhibits Complete the following sentence by using the list of options. The client is at risk for dropdownas evidenced by the client's dropdown

Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require dropdownas evidenced by the client's dropdown

The nurse continues to care for the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?

A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?