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 D

Explanation

A. Tertiary care Tertiary care refers to specialized medical care provided in hospitals for complex conditions (e.g., ICU care, cancer treatment, neurosurgery). It is not a self-care resource for caregivers.
B. Restorative care Restorative care focuses on rehabilitation and regaining function (e.g., physical therapy, speech therapy) rather than providing relief for caregivers.
C. Telemedicine care Telemedicine involves remote medical consultations, which can benefit clients but does not specifically address caregiver self-care needs.
D. Respite care Respite care provides temporary relief for caregivers by arranging for short-term professional care of their loved ones. This helps prevent caregiver burnout and supports self-care for those providing long-term assistance.

A. Rhythmic respirations B. Absent cry C. Resisting care D. Relaxed posturing

Correct Answer is C

Explanation

A. "Rhythmic respirations." Normal, rhythmic breathing is not typically associated with pain. Pain may cause labored, irregular, or rapid breathing.
B. "Absent cry." The FLACC scale assesses crying as an indicator of pain. However, an absent cry does not suggest pain. A strong, continuous cry or moaning may indicate discomfort.
C. "Resisting care." Clients with pain often resist movement, care, or interventions due to discomfort or distress. This is a key indicator of pain in the FLACC scale (Activity or Consolability sections).
D. "Relaxed posturing." A relaxed posture suggests comfort, while pain often leads to rigid or tense positioning.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is planning an in-service to teach families about self-care resources for caregivers. Which of the following programs should the nurse plan to include?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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