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.

Administer epinephrine to the client.

Obtain a prescription for a diuretic.

Administer oxygen to the client.

Answer and Explanation

Correct Answer : A,B,D,E

The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much ﬂuid too quickly during a blood transfusion.

c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a diﬀerent type of transfusion reaction.

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Correct Answer is B

Explanation

When providing preoperative teaching to a client over the phone in preparation for outpatient surgery, the nurse should explain the need for the client to have another adult drive them home following surgery. This is because the client may still be aﬀected by anesthesia and may not be able to safely operate a vehicle.

a. Asking the client to shower 3 times the day before surgery is not necessary and may dry out the skin.

c. The client should typically stop drinking clear liquids 2 hours before surgery, not 1 hour.

d. The client should not wear makeup during surgery as it can interfere with the monitoring of their skin color and oxygen saturation.

A. Fever B. Crackles in the lungs C. Bradycardia D. Flattened neck veins

Correct Answer is B

Explanation

Crackles in the lungs indicate that the client is experiencing ﬂuid overload. When there is an excess of ﬂuid in the body, it can accumulate in the lungs and cause crackles. The other

a. Fever is not a sign of ﬂuid overload.

c. Bradycardia (a slow heart rate) is not a sign of ﬂuid overload.

d. Flattened neck veins are not a sign of ﬂuid overload; distended neck veins may be a sign of ﬂuid overload.

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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 is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is assessing a client who is receiving continuous IV ﬂuids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing ﬂuid overload?

Correct Answer is B

Explanation

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