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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Loosening the bed linensmay not have a significant effect on the client's pain level, and may increase the risk of infection or further injury to the pressure ulcer.
B. Massaging the sacrum in the context of a pressure injury might exacerbate the condition and isn't recommended.
C. Providing bright lights might not specifically address the acute pain from the pressure injury.
D. Music therapy is a nonpharmacological intervention that can help reduce pain perception, anxiety, and stress in clients who have acute pain. Music can also provide distraction, relaxation, and comfort to the client.

A. Mini Nutritional Assessment screening tool score B. History of hyperlipidemia C. History of malnutrition D. History of diabetes mellitus E. Cholesterol level F. Prealbumin level

Correct Answer is ["C","D","F"]

Explanation

A. Mini Nutritional Assessment screening tool score: While it indicates the risk of malnutrition, it's not directly linked to delayed wound healing.
B. History of hyperlipidemia: Hyperlipidemia itself doesn't directly affect wound healing.
C. History of malnutrition: Malnutrition significantly hampers the body's ability to heal wounds effectively.
D. History of diabetes mellitus: Diabetes can impair wound healing due to poor blood sugar control affecting the immune system and circulation.
E. Cholesterol level: Elevated cholesterol, while relevant to overall health, is not directly linked to delayed wound healing.
F. Prealbumin level: Prealbumin is a marker for nutritional status; lower levels indicate inadequate protein intake and can contribute to delayed wound healing.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is caring for a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Correct Answer is ["C","D","F"]

Explanation

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