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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. The three-point gait is used when the client can only bear weight on one leg. In this gait, the client advances both crutches and the affected leg together, followed by the unaffected leg. This sequence involves the client using both crutches and the unaffected leg for support while keeping the affected leg non-weight-bearing.
A. The four-point alternating gait involves alternating the movement of each crutch with each step of the opposite leg. This gait is often used for clients who need maximum stability but can bear weight on both legs.
B. The two-point alternating gait also involves alternating the movement of each crutch with each step of the opposite leg. This gait provides a faster and more natural rhythm than the four-point gait but still requires bilateral weight-bearing ability.
C. The swing-through gait involves advancing both crutches forward, followed by swinging both legs through between the crutches. This gait is typically used by clients who have good upper body strength and can bear weight on both legs but have difficulty with normal leg advancement.
Correct Answer is B
Explanation
B. Ensuring the new ties are securely in place before removing the old ties prevents accidental displacement of the tracheostomy tube, which could lead to respiratory distress or other complications
A. Allowing space for three fingers under the ties would make the ties too loose, risking displacement of the tracheostomy tube. The correct practice is to allow space for one or two fingers to ensure the ties are snug enough to secure the tube without being too tight and causing discomfort or pressure injury.
C. Using a quick-release knot or Velcro ties is recommended because it allows for quick removal of the ties in case of an emergency, making it easier and faster to access the tracheostomy site if needed.
However, too loose knots can lead to dislodging of the tube.
D. Extending the client's neck while securing the ties is not recommended because it can cause discomfort and is not necessary for securing the tracheostomy ties. The client should be positioned comfortably with their neck in a neutral position to avoid unnecessary strain or discomfort.
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