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 C

Explanation

A. Obtaining a random blood glucose daily is important for monitoring glucose levels but might not be specifically related to the introduction of PN in this context.
B. Changing the PN infusion bag every 48 hours might not be universally applicable; the frequency of changing PN bags depends on institutional policies and the stability of the solution being administered.
C. PN with high concentrations of dextrose and fat emulsions typically requires a central venous line for administration to prevent peripheral vein irritation or damage.
D. Administering PN and fat emulsion separately might not be practical as PN usually includes all necessary components in a single infusion.

A. Eyelashes that curl slightly outward. B. Eyelids that blink involuntarily 30 to 35 times per minute. C. Pupils that are 8 to 9 mm in diameter. D. Corneas with an opaque appearance.

Correct Answer is A

Explanation

A. Eyelashes that curl slightly outward is a normal finding.
B. An involuntary blink rate of 30 to 35 times per minute might be within the normal range but is not typically assessed during a routine eye examination.
C. Pupils of 8 to 9 mm in diameter might indicate dilation, which is not a normal finding during a regular eye assessment.
D. Corneas with an opaque appearance could indicate issues such as corneal edema or opacity, which are abnormal findings.

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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

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Correct Answer is A

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