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.
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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Related Questions
Correct Answer is C
Explanation
If a client reports pain and informs the nurse that pain medications are not an option for managing their pain, the nurse can offer non-pharmacological interventions such as a back massage to help relieve the client's pain. This is an appropriate response by the nurse.
a. Telling the client that the pain medication will work if they just give it a chance is not an appropriate response as it dismisses the client's concerns and preferences.
b. The nurse should not recommend that the client take any herbal remedies without first consulting with the healthcare provider.
d. Asking the client why they think pain medication is not going to help them may be appropriate in some situations, but it is not necessarily the best initial response. The nurse should first offer non- pharmacological interventions to help relieve the client's pain.
Correct Answer is A
Explanation
When providing change-of-shift report about a client who has shingles, the nurse should include information about the type of transmission-based precautions in place to prevent the spread of infection to other clients and staff. Shingles is caused by the varicella-zoster virus and can be spread through direct contact with the rash.
- The times for routine vital sign measurements may be important information to include in the report, but it is not specific to the client's condition of shingles.
- The client's background health history may be important information to include in the report, but it is not specific to the client's condition of shingles.
- The number of visitors the client had during the shift may be important information to include in the report, but it is not specific to the client's condition of shingles.
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