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. Diuretics are used to reduce the fluid overload.
B. Administering oxygen helps alleviate hypoxia and support respiratory function.
C. Epinephrine is not indicated for these symptoms and could exacerbate the situation.
D. Stopping the transfusion is essential if transfusion-related complications are suspected.
E. Placing the client in high-Fowler's position helps optimize respiratory function and reduce fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Client advocate: By observing a newly licensed nurse perform a straight catheterization, the nurse manager is ensuring that the procedure is done correctly and safely, thereby advocating for the client's safety and quality of care.
B. Client care provider: The nurse manager is not directly providing the care but is overseeing the procedure to ensure it is performed correctly.
C. Case manager: The role of a case manager involves coordinating care and services for the client, not directly overseeing procedural performance.
D. Client educator: While there is an element of education involved, the primary focus of this observation is ensuring client safety and advocating for the best care practices, rather than directly teaching the procedure at this moment.
Correct Answer is A
Explanation
A. Offering to discuss what the client can expect during their stay provides support and helps address the client's anxiety by providing information.
B. Asking why the client is scared may put pressure on the client and does not provide immediate reassurance or support.
C. While acknowledging common feelings of anxiety is helpful, it may not directly address the client's concerns or provide reassurance.
D. Providing blanket reassurance without addressing the client's specific concerns may not effectively alleviate their anxiety and may come across as dismissive.
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