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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Cellulitis is a contraindication to receiving acupuncture treatment. Acupuncture involves the insertion of needles into the skin, and if the client has an active skin infection such as cellulitis, there is a risk of spreading the infection.

Option a is incorrect because hypertension is not a contraindication to receiving acupuncture.

Option c is incorrect because obesity is not a contraindication to receiving acupuncture.

Option d is incorrect because migraines are not a contraindication to receiving acupuncture; in fact, acupuncture may be used to treat migraines.

A. I will use a pumice stone to soften calluses on my feet. B. I will go barefoot just in the house. C. I can apply lotion to my feet if I avoid the area between my toes. D. I can use a heating pad when my feet are cold. E. I can use a heating pad when my feet are cold.

Correct Answer is C

Explanation

The correct answer is that the client can apply lotion to their feet if they avoid the area between their toes. Moisturizing the feet can help prevent dry skin and cracking, which are common problems for people with diabetes. However, it is important to avoid applying lotion between the toes, as this can create a moist environment that promotes the growth of fungus and bacteria¹.

Options a, b and d are not correct statements by the client that indicate an understanding of proper foot care for diabetes. Using a pumice stone to soften calluses on the feet, going barefoot just in the house and using a heating pad when feet are cold are not recommended practices for people with diabetes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a client who has chronic back pain and asks about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this treatment?

Correct Answer is B

Explanation

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has a new diagnosis of a terminal illness. The client states, "I do not want any treatment. I would like to go home." Which of the following responses should the nurse make?

A nurse is providing teaching to a client about the administration of clotrimazole vaginal suppositories. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

A nurse is caring for a group of clients whose primary languages are diﬀerent from the nurse's. For which of the following clients should the nurse provide written materials in the client's primary language?

A nurse enters a client's room and discovers a smoldering fire in the drapes. After moving clients to a safe location, which of the following actions should the nurse take next?

A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching?

A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?

A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?