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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 D

Explanation

A. While mental health support can be valuable for the adolescent, the priority is to address the immediate financial and healthcare concerns. Referring to a mental health clinic is not the best first step.
B. Contacting the adolescent's parent may breach the adolescent's confidentiality and autonomy. The adolescent is capable of making her own decisions, and consent from the parent is not necessary unless the adolescent is a minor or unable to make decisions.
C. Advising adoption is a significant decision and should not be presented as a first option. The adolescent should be given the opportunity to explore all of her options with support, including parenting and financial assistance.
D. Assisting the adolescent in applying for Medicaid is an appropriate action as it will provide financial support for medical care, which can help her address concerns about affording and caring for the baby.

A. Refute the client's delusions using logic. B. Give the client one simple direction at a time. C. Establish eye contact when communicating with the client. D. Allow the client to choose among a variety of activities each day. E. Reinforce orientation to time, place, and person.

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

Explanation

A. Refuting delusions using logic can increase agitation and confusion. Instead, the nurse should offer reassurance and validation without arguing.
B. Giving the client one simple direction at a time helps minimize confusion and enhances the client’s
ability to follow instructions.
C. Establishing eye contact is important for communication and shows attentiveness, helping the client feel connected.
D. Allowing the client to choose among activities provides a sense of autonomy and can reduce agitation.
E. Reinforcing orientation helps maintain the client’s awareness of time, place, and person, which can reduce disorientation and anxiety.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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.)

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

Explanation

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority?

A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?

A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?