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. A feeling of swelling in the feet: Swelling in the feet can be caused by various factors such as fluid retention, circulatory issues, or certain medical conditions like venous insufficiency. It is not a typical symptom of anaphylaxis, which usually involves more generalized symptoms such as hives, itching, swelling of the face or throat, difficulty breathing, and a drop in blood pressure.

B. Pain at the injection site: Pain at the injection site is a common side effect of receiving an injection or medication. It occurs due to tissue irritation or trauma from the needle. While allergic reactions can cause localized redness, swelling, or itching at the injection site, severe pain alone is not a hallmark symptom of anaphylaxis.

C. A sudden decrease in heart rate: Anaphylaxis typically leads to an increase in heart rate (tachycardia) rather than a decrease. This increase in heart rate is a response to the body's attempt to compensate for the drop in blood pressure caused by anaphylaxis. Bradycardia (a decrease in heart rate) is not a typical feature of anaphylaxis unless it occurs very late in a severe reaction due to profound circulatory collapse.

D. A sharp decrease in blood pressure: This choice is indicative of an understanding of possible anaphylaxis. Anaphylaxis can cause a rapid and severe drop in blood pressure, known as hypotension. This drop in blood pressure is often a key feature of anaphylaxis and can lead to symptoms such as dizziness, fainting, confusion, and shock.

A. Place the sterile field at the level of the nurse's hips. B. Hold bottles of sterile solution with the label in the palm of the hand. C. Open the outermost flap of the sterile kit toward the body. D. Pour liquids into containers outside the sterile field

Correct Answer is B

Explanation

A.Place the sterile field at the level of the nurse’s hips: This is not a recommended action. The sterile field should be placed at waist level or slightly above to ensure easy access and prevent contamination.

B. Hold bottles of sterile solution with the label in the palm of the hand: This protects the label from becoming wet and illegible, which is proper sterile technique.

C. Open the outermost flap of the sterile kit toward the body: When opening a sterile kit or package, the nurse should open the outermost flap away from the body to prevent contamination. Opening the flap toward the body increases the risk of airborne particles or contaminants from the nurse's clothing or skin entering the sterile field.

D. Sterile liquids should be poured into sterile containers on the sterile field, taking care not to contaminate the field.

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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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