A nurse is caring for a client in a medical-surgical unit

A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition:

Transfusion-associated circulatory overload (TACO)

Actions the Nurse Should Take:

Stop transfusion (D): This is crucial to prevent further fluid overload and worsening symptoms.
Administer furosemide (C): Furosemide is a loop diuretic that can help remove excess fluid and alleviate symptoms of fluid overload.

Parameters to Monitor:

Weight (B): Monitor weight to assess for fluid retention and overload.
Respiratory rate (C): Monitor respiratory rate closely for signs of respiratory distress such as dyspnea and increased effort.

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Correct Answer is B

Explanation

Correct answer: B

A. Myopia - Myopia (near-sightedness) is a vision condition related to the shape of the eye and is not related to Meniere's disease or endolymph fluid accumulation.

B. Vertigo - Vertigo is a primary symptom of Meniere's disease and is caused by the excessive accumulation of endolymph fluid in the inner ear, which affects balance and spatial orientation.

C. Photophobia - Sensitivity to light is not a symptom of Meniere's disease; it is more commonly associated with migraines or eye conditions.

D. Presbycusis - Presbycusis is age-related hearing loss and is unrelated to the fluid balance issues seen in Meniere's disease.

A. Avoid crowds B. Eat plenty of fresh fruits and vegetables C. Take temperature weekly. D. Perform mild exercise, such as gardening

Correct Answer is A

Explanation

A. Avoid crowds - Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens.

B. Eat plenty of fresh fruits and vegetables - While generally healthy, fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Cooked or properly washed and peeled produce is safer.

C. Take temperature weekly - Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early.

D. Perform mild exercise, such as gardening - Gardening can expose individuals to soil-borne organisms that could lead to infections. Indoor exercises or those that don’t involve potential pathogen exposure are safer.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

In reviewing a patient’s complete blood count (CBC) results, the nurse notes a "shift to the left." What is the significance of these results?

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A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

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