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 epinephrine to the client.

Administer oxygen to the client.

Obtain a prescription for a diuretic.

Stop the transfusion.

Answer and Explanation

Correct Answer : A,C,E

A. Place the client in high-Fowler's position: Placing the client in high-Fowler's position (sitting up at a 90-degree angle) can help improve oxygenation by optimizing lung expansion. This position facilitates better respiratory mechanics and can be beneficial for clients experiencing respiratory distress.

B. Administering epinephrine to the client: Epinephrine is not indicated for the management of fluid overload or transfusion reactions characterized by respiratory symptoms such as TRALI. Therefore, this action is not appropriate in this scenario.

C. Administer oxygen to the client: Hypoxia is a serious concern and requires immediate intervention. Administering oxygen will help improve oxygenation and alleviate respiratory distress.

D. Obtaining a prescription for a diuretic: While diuretics may be indicated in some cases of fluid overload, their use should be guided by the healthcare provider's assessment and prescription. Obtaining a prescription for a diuretic may be considered after the transfusion has been stopped and the healthcare provider has evaluated the client.

E. Stop the transfusion: The presence of lung crackles, hypoxia, and distended neck veins suggests fluid overload, which can be a sign of transfusion-related acute lung injury (TRALI) or circulatory overload. Stopping the transfusion is essential to prevent further fluid overload and worsening of respiratory symptoms.

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Correct Answer is D

Explanation

A. Supine in low-Fowler's position:Low-Fowler's position does not effectively promote postural drainage for left lower-lobe atelectasis. This position would not use gravity to facilitate mucus drainage or improve ventilation to the affected lobe.

B. Side-lying with the right side of the chest elevated:While side-lying positions can be useful for postural drainage, lying with the right side elevated does not optimize drainage from the left lower lobe.

C. Prone with pillows under the lower extremities:Although the prone position can help improve oxygenation in some respiratory conditions, it is not ideal for targeting left lower-lobe atelectasis in postural drainage therapy.

D. Right lateral in Trendelenburg position:In this position, the left lower lobe is elevated, allowing gravity to assist in draining secretions toward the larger airways for clearance. The Trendelenburg position further enhances the effect of gravity on secretion drainage from the lower lobe.

A. assault B. Defamation C. Battery D. Invasion of privacy

Correct Answer is A

Explanation

A. Assault.

Assault is the threat or apprehension of harmful or offensive contact. In this scenario, the nurse is making a threat to administer medication by injection if the client doesn't comply with swallowing pills. Even though the nurse hasn't physically carried out the action yet, the threat itself constitutes assault. The client feels threatened by the nurse's statement, creating apprehension of harm or offensive contact.

B. Defamation: Defamation involves making false statements that harm a person's reputation. There is no indication of defamation in this scenario.

C. Battery: Battery involves the intentional and unauthorized touching of another person. While administering medication by injection without consent could be considered battery, the nurse has only made a threat at this point, not carried out the action.

D. Invasion of privacy: Invasion of privacy involves intruding into someone's private affairs without permission. There is no indication of invasion of privacy in this scenario.

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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

A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?

Correct Answer is D

Explanation

A nurse manager overhears a nurse telling a client, "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts?

Correct Answer is A

Explanation

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