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.)

Obtain a prescription for a diuretic

Administer oxygen to the client.

Administer epinephrine to the client.

Stop the transfusion.

Place the client in high-Fowler's position.

Answer and Explanation

Correct Answer : A,B,D,E

A. Obtaining a prescription for a diuretic may also be necessary to manage fluid overload
B Administering oxygen is essential to correct hypoxia, which is indicated by the client's symptoms of lung crackles and hypoxia. Oxygen therapy helps improve oxygenation and alleviate respiratory distress.
D. Stopping the transfusion is crucial because the client's symptoms, including lung crackles, hypoxia, and distended neck veins, suggest a potential transfusion reaction, such as transfusion-associated circulatory overload (TACO).
E. Placing the client in high-Fowler's position, with the head of the bed elevated to 90 degrees or as high as tolerated, helps improve ventilation and reduce venous return to the heart, which can alleviate symptoms of fluid overload and respiratory distress.
C. Administering epinephrine is not indicated in this situation as it is typically used for anaphylactic reactions, not circulatory overload.

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Correct Answer is C

Explanation

C. This finding suggests a swallowing difficulty (dysphagia), which is a significant concern for clients with left-sided weakness following a stroke. Dysphagia increases the risk of aspiration, choking, and pneumonia. Immediate intervention is necessary to prevent complications and ensure safe oral intake.
A. While elevated blood pressure may be a concern for a client with a history of stroke, it is not the priority finding in this scenario unless it is significantly high or symptomatic. The immediate priority is addressing issues related to the client's physical function and safety.
B. Malnutrition and dehydration are common risks for clients with left-sided weakness following a stroke. Ensuring adequate nutrition and hydration is essential for promoting recovery and preventing complications such as pressure ulcers and infections.
D. While leaning to one side may indicate asymmetrical weakness or impaired balance, it is not the priority finding compared to issues related to nutrition, swallowing safety, and blood pressure control.

A. Participation in competitive sports B. Metabolic syndrome C. Family history of alcohol use disorder D. Hypotensi

Correct Answer is B

Explanation

B. Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of heart disease, stroke, and type 2 diabetes. These conditions include high blood pressure, high blood sugar levels, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.
A. Participation in competitive sports may promote cardiovascular health through physical activity, reducing the risk of cardiovascular disease in most cases.
C. Family history of alcohol use disorder is not a direct risk factor for cardiovascular disease. However, excessive alcohol consumption itself can contribute to cardiovascular problems.
D. Hypotension, or low blood pressure, is not typically considered a risk factor for cardiovascular disease. In fact, it may be associated with a reduced risk of certain cardiovascular conditions such as hypertension and coronary artery disease. However, severe hypotension may lead to inadequate blood flo to the heart and brain, potentially causing cardiovascular complications.

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A nurse is caring for a client

Exhibits

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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 assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a client Exhibits

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