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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.)

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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.

B. This is the safest method to prevent accidental dislodgement of the tracheostomy tube. By securing the new ties first, the tracheostomy tube remains in place, reducing the risk of complications.
C. A secure knot that can be released quickly in case of emergency is recommended.

D. Extending the client's neck during tie securing can cause discomfort and respiratory compromise. The client's neck should be in a neutral position.

A. A nurse begins a blood transfusion without obtaining consent from a client. B. An assistive personnel discusses client care in the facility cafeteria with visitors present. C. A nurse administers a medication without first identifying the client. D. An assistive personnel prevents a client from leaving the facility.

Correct Answer is C

Explanation

A. Beginning a blood transfusion without consent is a breach of ethical principles, but it's not specifically negligence unless harm results.
B. Discussing client care in a public area violates privacy regulations and facility policy but is not an example of negligence.
C. Administering medication without properly identifying the client violates standard procedures and could lead to medication errors, which is a form of negligence.
D. Preventing a client from leaving the facility may be necessary to ensure their safety, depending on the circumstances, and is not necessarily an example of negligence.

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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

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