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 A

Explanation

A. “I need something for the pain in my eye. I can't stand it." Severe pain after cataract surgery is unusual and could indicate complications such as increased intraocular pressure or infection. This should be reported immediately to the provider for further evaluation.

B. "It’s hard to see with a patch on one eye. I'm afraid of falling": This is a common concern and relates to mobility safety, not a sign of a surgical complication.

C. "My eye really itches, but I'm trying not to rub it.": Itching can be a normal response post-surgery due to healing. Patients should avoid rubbing the eye, and this does not necessarily indicate a complication.

D. "The bright light in this room is really bothering me.": Photophobia or sensitivity to light can be common postoperatively and is usually not a sign of a serious issue.

A. 4 hr B. 2 hr C. 8 hr D. 6 hr

Correct Answer is A

Explanation

A. 4 hr - The total infusion time for packed RBCs should not exceed 4 hours. Infusing beyond this period increases the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications.

B. 2 hr - While blood can be infused in 2 hours for some patients, especially in non-emergent situations, the standard maximum time allowed is 4 hours to prevent complications.

C. 8 hr - Infusing blood over 8 hours is too long and increases the risk of bacterial contamination and decreased efficacy of the blood product.

D. 6 hr - Similar to 8 hours, a 6-hour infusion time is too lengthy and poses significant risks for bacterial growth and sepsis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

Correct Answer is A

Explanation

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

Correct Answer is A

Explanation

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