A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Stop the transfusion.

Place the client in high-Fowler's position.

Obtain a prescription for a diuretic.

Administer oxygen to the client.

Administer epinephrine to the client.

Answer and Explanation

Correct Answer : A,B,C,D

A. Stop the transfusion. The first action is to stop the transfusion to prevent further fluid overload.
B. Place the client in high-Fowler's position. This position reduces venous return to the heart and improves breathing and oxygenation.
C. Obtain a prescription for a diuretic. Diuretics (e.g., furosemide) help remove excess fluid, relieving pulmonary congestion and reducing strain on the heart.
D. Administer oxygen to the client. Oxygen helps relieve hypoxia caused by fluid buildup in the lungs.
E. Administer epinephrine to the client. Epinephrine is used for anaphylactic reactions, not circulatory overload. There is no indication of an allergic reaction in this scenario.

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Correct Answer is B

Explanation

A. "Although this is your first incident, we will have to terminate your employment." This response is punitive and does not align with a just culture, which seeks to identify the cause of errors rather than immediately disciplining staff.
B. "We will review the incident report to determine the cause of the missed medication." This aligns with just culture principles by focusing on finding the root cause (e.g., workload issues, system inefficiencies) rather than blaming the nurse.
C. "I will need to report this incident to the state board of nursing." A missed medication dose that caused no harm typically does not require reporting to the state board. Just culture focuses on improving processes rather than unnecessary punishment.
D. "The facility's legal team will be contacting you to discuss the incident." Involving legal action for a minor, non-harmful event is excessive and contradicts just culture, which emphasizes education, accountability, and system improvements over legal consequences.

A. The client cannot change their mind after signing consent. B. The alternative treatments to the procedure should be explained. C. The time of the procedure should be indicated on the form. D. The charge nurse should review the form once it's signed.

Correct Answer is B

Explanation

A. The client cannot change their mind after signing consent. Clients have the right to withdraw consent at any time before the procedure begins.
B. The alternative treatments to the procedure should be explained. Informed consent includes information about alternative treatments and their risks/benefits so the client can make an informed decision.
C. The time of the procedure should be indicated on the form. The time of the procedure is not a required component of informed consent. The consent form should include the procedure details, risks, benefits, and alternatives
D. The charge nurse should review the form once it's signed. While nurses witness informed consent, they do not validate or review it. The provider performing the procedure is responsible for obtaining consent.

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A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has initiated an incident report for a missed dose of medication on a client that caused no harm to the client. Which of the following responses by the nurse manager indicates the use of just culture?

Correct Answer is B

Explanation

A nurse is teaching a group of students about the components of informed consent. Which of the following should the nurse include?

Correct Answer is B

Explanation

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