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.)
Place the client in high-Fowler's position.
Administer oxygen to the client.
Stop the transfusion.
Obtain a prescription for a diuretic.
Administer epinephrine to the client.
Correct Answer : A,B,C
A. Placing the client in high Fowler's position helps improve lung expansion and oxygenation.
B. Administering oxygen helps address hypoxia and supports adequate oxygenation.
C. Stopping the transfusion is crucial when signs of a transfusion reaction are present.
D. Administering a diuretic is not typically indicated for transfusion reactions involving lung crackles, hypoxia, and distended neck veins.
E. Epinephrine is not typically used to manage a blood transfusion reaction; it's more for severe allergic reactions like anaphylaxis.
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Related Questions
Correct Answer is C
Explanation
A. Eyewear should be removed after the gown as part of the sequence to prevent exposure to potential contaminants.
B. The mask should be removed after the gown to prevent contamination of the nurse's face.
C. The nurse should follow the sequence of doffing personal protective equipment (PPE) recommended by the Centers for Disease Control and Prevention (CDC) to prevent contamination. The sequence is: gloves, gown, eyewear, and mask. Gloves are the most contaminated piece of PPE and should be removed first by grasping the outside of one glove at the wrist and peeling it off, then holding it in the gloved hand and sliding the fingers of the ungloved hand under the remaining glove at the wrist and peeling it off over the first glove. The nurse should then discard both gloves in a waste container.
D. The gown is removed after the gloves when leaving the room to prevent carrying any potential contaminants outside the patient's room and to maintain infection control measures.
Correct Answer is A
Explanation
A. The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B. The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C. In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D. Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.
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